Healthcare Provider Details

I. General information

NPI: 1033729397
Provider Name (Legal Business Name): KATHLEEN O'NEILL GREENE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WALTON WAY
ROSWELL GA
30076-3418
US

IV. Provider business mailing address

215 JEFFREY DR
WOODSTOCK GA
30188-2323
US

V. Phone/Fax

Practice location:
  • Phone: 470-306-0652
  • Fax:
Mailing address:
  • Phone: 423-718-2690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License NumberPT006568
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: