Healthcare Provider Details

I. General information

NPI: 1114181088
Provider Name (Legal Business Name): DIANE BEVEN GREEN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14444 BEACH BLVD
JACKSONVILLE FL
32250-2079
US

IV. Provider business mailing address

112 PARKSIDE DR
SAINT AUGUSTINE FL
32095
US

V. Phone/Fax

Practice location:
  • Phone: 904-858-7510
  • Fax: 904-858-7540
Mailing address:
  • Phone: 904-825-4275
  • Fax: 904-810-7635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT11283
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: