Provider Demographics
NPI:1174520712
Name:VANDERVORT, AMANDA JOY (MPT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JOY
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JOY
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:5000 ROCKSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2178
Mailing Address - Country:US
Mailing Address - Phone:216-459-2846
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:5520 BROADVIEW RD FRNT
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1605
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:216-749-1655
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT010156225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2353797Medicaid
OH11896519OtherCAQH