Healthcare Provider Details

I. General information

NPI: 1376213298
Provider Name (Legal Business Name): HAYDEN LEE GREEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HAYDEN LEE GREEN PTA

II. Dates (important events)

Enumeration Date: 09/14/2021
Last Update Date: 04/06/2024
Certification Date: 04/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

231 34TH AVE SW
NORMAN OK
73072-4843
US

IV. Provider business mailing address

231 34TH AVE SW
NORMAN OK
73072-4843
US

V. Phone/Fax

Practice location:
  • Phone: 405-593-8353
  • Fax: 888-558-6690
Mailing address:
  • Phone: 405-593-8353
  • Fax: 888-558-6690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2758
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: