Provider Demographics
NPI:1689801607
Name:ROSENTHAL, AMANDA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:ROSENTHAL
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 1:17818 OAK PARK AVE
Mailing Address - Street 2:APT 2S
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3964
Mailing Address - Country:US
Mailing Address - Phone:708-570-4033
Mailing Address - Fax:
Practice Address - Street 1:100 W PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:COUNTRYSIDE
Practice Address - State:IL
Practice Address - Zip Code:60525-2869
Practice Address - Country:US
Practice Address - Phone:708-588-0833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008632225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3942809YMedicaid