Provider Demographics
NPI:1699073460
Name:WIRTH, AMANDA (PT, DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WIRTH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BOLTON CT
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-4738
Mailing Address - Country:US
Mailing Address - Phone:631-278-2680
Mailing Address - Fax:
Practice Address - Street 1:3575 QUAKERBRIDGE RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-1205
Practice Address - Country:US
Practice Address - Phone:609-631-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA013855002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics