MEDICARE: CHRISTINE GREEN PT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician	PT00005215	WA

General Provider Information

NPI Number	:	1528052172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE GREEN PT, ATC

Provider Business Mailing Address
First Line	:	3420 ILLINOIS ST
Second Line	:
City	:	GREAT LAKES
State	:	IL
Zip	:	60088-3161
Country	:	US
Telephone Number	:	847-688-6755
Fax Number	:

Provider Business Practice Location Address
First Line	:	7822 28TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53143-5622
Country	:	US
Telephone Number	:	262-764-0754
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	03/07/2016

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