Provider Demographics
NPI:1902331093
Name:GREEN, LATOYA L (DPT)
Entity Type:Individual
Prefix:
First Name:LATOYA
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LATOYA
Other - Middle Name:
Other - Last Name:NANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 MADISON AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3469
Mailing Address - Country:US
Mailing Address - Phone:901-448-5888
Mailing Address - Fax:901-448-1411
Practice Address - Street 1:920 MADISON AVE SUITE 415
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-1614
Practice Address - Country:US
Practice Address - Phone:901-448-5888
Practice Address - Fax:901-448-1411
Is Sole Proprietor?:No
Enumeration Date:2017-04-26
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3861225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3133295OtherBC/BS
TN0446645Medicaid
TN446645OtherMEDICARE