Provider Demographics
NPI:1053814566
Name:GRYCKI, AMANDA (OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:GRYCKI
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 LAKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-9759
Mailing Address - Country:US
Mailing Address - Phone:907-205-9381
Mailing Address - Fax:
Practice Address - Street 1:1 STATE RD STE 3
Practice Address - Street 2:
Practice Address - City:NEWAYGO
Practice Address - State:MI
Practice Address - Zip Code:49337-7982
Practice Address - Country:US
Practice Address - Phone:231-923-8092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-10
Last Update Date:2018-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201009877225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist