Provider Demographics
NPI:1730740713
Name:GLAZEWSKI, AMANDA (DPT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GLAZEWSKI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:SHUMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:
Practice Address - Street 1:1261 S LAPEER RD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1419
Practice Address - Country:US
Practice Address - Phone:248-690-8030
Practice Address - Fax:248-690-8029
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019042225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist