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General NPI Number Information
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NPI Number | 1821656950
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Entity Type | Individual
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Provider Name | AMANDA ILLA PICKWORTH-CHRUSCIEL PT, DPT
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Gender | Female
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Dates
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Enumeration Date | 06/04/2019
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 17783 HAGGERTY RD STE B
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City | NORTHVILLE CHARTER TOWNSHIP
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State | MI
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Zip | 48168-9802
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Country | US
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Telephone | 734-895-1901
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Fax | 855-794-1008
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Provider Business Mailing Address
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Address Line | 5536 RESEARCH DR STE A
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City | CANTON
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State | MI
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Zip | 48188-2261
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Country | US
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Telephone | 734-895-1901
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Fax | 855-794-1008
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 5502003904
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License Number State | MI
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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 | 5501303770
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License Number State | MI
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