Healthcare Provider Details

I. General information

NPI: 1366631699
Provider Name (Legal Business Name): TARA LEA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2007
Last Update Date: 10/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 INTERNATIONAL PKWY 2051
HEATHROW FL
32746-5303
US

IV. Provider business mailing address

8 MILLER ST
CANTON NC
28716-3827
US

V. Phone/Fax

Practice location:
  • Phone: 800-798-6035
  • Fax:
Mailing address:
  • Phone: 828-508-0833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number7679A
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: