Provider Demographics
NPI:1972263572
Name:WELLMAN, AMANDA LEE (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:BLOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 419885
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9885
Mailing Address - Country:US
Mailing Address - Phone:888-830-4125
Mailing Address - Fax:
Practice Address - Street 1:12319 HIGHLAND RD STE 501
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2946
Practice Address - Country:US
Practice Address - Phone:810-991-1211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-22
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501021613225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist