Provider Demographics
NPI:1073161188
Name:GREEN, ALEXIS NICOLE
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7866 AMERICANA CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21060-5445
Mailing Address - Country:US
Mailing Address - Phone:443-859-4318
Mailing Address - Fax:
Practice Address - Street 1:7355 E FURNACE BRANCH RD
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21060-7060
Practice Address - Country:US
Practice Address - Phone:410-766-3460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-01
Last Update Date:2019-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty