Provider Demographics
NPI:1063916831
Name:WINTERS, AMANDA L
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:WINTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 N CARPENTER ST APT PHN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2172
Mailing Address - Country:US
Mailing Address - Phone:419-366-3645
Mailing Address - Fax:419-366-3645
Practice Address - Street 1:805 N MILWAUKEE AVE STE 102
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1257
Practice Address - Country:US
Practice Address - Phone:419-366-3645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-19
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070023536225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist