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General NPI Number Information
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NPI Number | 1497256093
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Entity Type | Individual
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Provider Name | AMANDA LYN MENINNO ATC, DPT
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Gender | Female
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Dates
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Enumeration Date | 02/28/2018
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Last Update Date | 02/28/2018
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Provider Practice Location Address
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Address Line | 16001 W 9 MILE RD
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City | SOUTHFIELD
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State | MI
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Zip | 48075-4818
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Country | US
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Telephone | 248-849-3465
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Fax |
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Provider Business Mailing Address
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Address Line | 4408 AUBURN DR
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City | ROYAL OAK
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State | MI
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Zip | 48073-6346
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Country | US
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Telephone | 781-258-2190
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501017739
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License Number State | MI
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