MEDICARE: AMANDA TIEKEN PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	005800	KY
2	225100000X	Physical Therapist	05010550A	IN

General Provider Information

NPI Number	:	1568741148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA TIEKEN PT, DPT

Provider Business Mailing Address
First Line	:	8807 SHELBYVILLE RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46259-9695
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11315 CORPORATE BLVD STE 100
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32817-8340
Country	:	US
Telephone Number	:	502-657-9877
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2011
Last Update Date	:	08/12/2011

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