Provider Demographics
NPI:1699107722
Name:ELLIOTT, AMANDA (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6150 QUINWOOD LN N
Mailing Address - Street 2:#5104
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-1301
Mailing Address - Country:US
Mailing Address - Phone:815-275-7006
Mailing Address - Fax:
Practice Address - Street 1:6701 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4602
Practice Address - Country:US
Practice Address - Phone:952-993-5495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11713-024225100000X
MN9481225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist