Healthcare Provider Details

I. General information

NPI: 1740680479
Provider Name (Legal Business Name): AMIRA DEMITRY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2014
Last Update Date: 08/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10233 W ROOSEVELT RD
WESTCHESTER IL
60154-2518
US

IV. Provider business mailing address

430 HOMESTEAD RD APT 3
LA GRANGE PARK IL
60526-2158
US

V. Phone/Fax

Practice location:
  • Phone: 708-938-5238
  • Fax: 708-938-5239
Mailing address:
  • Phone: 850-319-6630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: