Healthcare Provider Details

I. General information

NPI: 1356685382
Provider Name (Legal Business Name): KRISTINA LYNNE GREEN OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA STAFFORD OT

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11110 TOM ADAMS DR
AUSTIN TX
78753-3354
US

IV. Provider business mailing address

501 FOREST LN SUITE A
CLEMSON SC
29631-2621
US

V. Phone/Fax

Practice location:
  • Phone: 512-836-1515
  • Fax: 855-232-8604
Mailing address:
  • Phone: 864-654-2001
  • Fax: 800-305-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2729
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number118743
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: