Healthcare Provider Details

I. General information

NPI: 1629013602
Provider Name (Legal Business Name): AMANDA GAYLE MCCULLOUGH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 SCHOOLCREST AVE
CLARE MI
48617-1145
US

IV. Provider business mailing address

107 SCHOOLCREST AVE
CLARE MI
48617-1145
US

V. Phone/Fax

Practice location:
  • Phone: 989-386-9170
  • Fax: 989-386-9220
Mailing address:
  • Phone: 989-386-9170
  • Fax: 989-386-9220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011835
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: