Provider Demographics
NPI:1912284118
Name:HADDAD, 393AMANDA JENNIFER (PT)
Entity Type:Individual
Prefix:
First Name:393AMANDA
Middle Name:JENNIFER
Last Name:HADDAD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JENNIFER
Other - Last Name:GEDNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2743 MARBLEVISTA BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-9016
Mailing Address - Country:US
Mailing Address - Phone:440-759-8709
Mailing Address - Fax:
Practice Address - Street 1:4255 NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND HILLS
Practice Address - State:OH
Practice Address - Zip Code:44128-2811
Practice Address - Country:US
Practice Address - Phone:216-292-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT.013498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0028740Medicaid
OH9290211Medicare PIN