MEDICARE: KRISTIN KATHLEEN GREEN DPT, OCS

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	2251X0800X	Orthopedic Physical Therapist
2	225100000X	Physical Therapist	PTP-PT-LIC-2068	MT

General Provider Information

NPI Number	:	1669676912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN KATHLEEN GREEN DPT, OCS

Provider Business Mailing Address
First Line	:	2740 SOUTH AVE W STE 101
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-5137
Country	:	US
Telephone Number	:	406-543-0617
Fax Number	:	406-728-1085

Provider Business Practice Location Address
First Line	:	2740 SOUTH AVE W STE 101
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59804-5137
Country	:	US
Telephone Number	:	406-543-0617
Fax Number	:	406-728-1085

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

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	05/15/2019

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