Healthcare Provider Details

I. General information

NPI: 1184125155
Provider Name (Legal Business Name): AMANDA MIUCCIO MOTL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2018
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5570 WHITTAKER RD
YPSILANTI MI
48197-9752
US

IV. Provider business mailing address

1168 COVENTRY SQUARE DR
ANN ARBOR MI
48103-6300
US

V. Phone/Fax

Practice location:
  • Phone: 734-842-1200
  • Fax:
Mailing address:
  • Phone: 734-846-4750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201007301
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: