Healthcare Provider Details

I. General information

NPI: 1306145115
Provider Name (Legal Business Name): AMANDA MICHELLE WIZINSKY PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 COMMONWEALTH BLVD
ANN ARBOR MI
48105-2970
US

IV. Provider business mailing address

1309 FOUNTAIN ST
ANN ARBOR MI
48103-2962
US

V. Phone/Fax

Practice location:
  • Phone: 734-763-2554
  • Fax:
Mailing address:
  • Phone: 513-525-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number5501302887
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number070.017461
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: