Provider Demographics
NPI:1285886291
Name:GILLIGAN, AMANDA EAGLESON (PT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:EAGLESON
Last Name:GILLIGAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 WESTMINSTER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1441
Mailing Address - Country:US
Mailing Address - Phone:516-993-0915
Mailing Address - Fax:
Practice Address - Street 1:452 WESTMINSTER RD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1441
Practice Address - Country:US
Practice Address - Phone:516-993-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014810-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics