Provider Demographics
NPI:1063823730
Name:GREEN, CONSTANCE ALEXIS (AUD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:ALEXIS
Last Name:GREEN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13904 N DALE MABRY HWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-2446
Mailing Address - Country:US
Mailing Address - Phone:813-908-2020
Mailing Address - Fax:813-908-2133
Practice Address - Street 1:13904 N DALE MABRY HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2446
Practice Address - Country:US
Practice Address - Phone:813-908-2020
Practice Address - Fax:813-908-2133
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAZ663231H00000X
FLAY1892231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist