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General NPI Number Information
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NPI Number | 1528052172
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Entity Type | Individual
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Provider Name | CHRISTINE GREEN PT, ATC
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Gender | Female
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 03/07/2016
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Provider Practice Location Address
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Address Line | 7822 28TH AVE
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City | KENOSHA
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State | WI
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Zip | 53143-5622
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Country | US
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Telephone | 262-764-0754
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Fax |
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Provider Business Mailing Address
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Address Line | 3420 ILLINOIS ST
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City | GREAT LAKES
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State | IL
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Zip | 60088-3161
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Country | US
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Telephone | 847-688-6755
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247200000X
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Taxonomy Name | Other Technician
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License Number | PT00005215
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License Number State | WA
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