Provider Demographics
NPI:1003286105
Name:GREEN, KATHRYN (OT R/L)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OT R/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-2534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:SOUND BEACH
Practice Address - State:NY
Practice Address - Zip Code:11789-2534
Practice Address - Country:US
Practice Address - Phone:631-821-1477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0717371-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0717371-1OtherNYS