Provider Demographics
NPI:1962750281
Name:GRUSS, AMANDA LYNN (PTA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYNN
Last Name:GRUSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E. 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46075
Mailing Address - Country:US
Mailing Address - Phone:574-835-0991
Mailing Address - Fax:
Practice Address - Street 1:275 W 12TH ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970
Practice Address - Country:US
Practice Address - Phone:765-475-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004466A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant