Healthcare Provider Details

I. General information

NPI: 1578442539
Provider Name (Legal Business Name): KYLIE RAE GREEN OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2025
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CLEMENTS RD
COTTONDALE AL
35453-2137
US

IV. Provider business mailing address

11317 CRIMSON RIDGE RD
BROOKWOOD AL
35444-0857
US

V. Phone/Fax

Practice location:
  • Phone: 205-752-7691
  • Fax:
Mailing address:
  • Phone: 407-782-6703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number6753
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: