Provider Demographics
NPI:1043736101
Name:GREEN, NICOLE RENE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57747-1480
Mailing Address - Country:US
Mailing Address - Phone:605-745-2000
Mailing Address - Fax:
Practice Address - Street 1:500 N 5TH ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:SD
Practice Address - Zip Code:57747-1480
Practice Address - Country:US
Practice Address - Phone:605-745-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2374225X00000X
COOT.0005127225X00000X
SD1158225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist