Provider Demographics
NPI:1538403050
Name:GREEN, CARIE LYNNE (PTA)
Entity type:Individual
Prefix:
First Name:CARIE
Middle Name:LYNNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 JAMES WAY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-7801
Mailing Address - Country:US
Mailing Address - Phone:740-389-6306
Mailing Address - Fax:
Practice Address - Street 1:524 JAMES WAY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-7801
Practice Address - Country:US
Practice Address - Phone:740-389-6306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA. 06719225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant