Healthcare Provider Details

I. General information

NPI: 1699397802
Provider Name (Legal Business Name): AMANDA PISANI OTR/L, QMHP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 05/11/2020
Certification Date: 05/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W GREENLEAF AVE
CHICAGO IL
60626-2805
US

IV. Provider business mailing address

3642 N WAYNE AVE
CHICAGO IL
60613-3714
US

V. Phone/Fax

Practice location:
  • Phone: 773-508-6100
  • Fax:
Mailing address:
  • Phone: 773-208-2063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.013503
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: