Provider Demographics
NPI:1073907374
Name:GREEN, PRESTON II (COTA)
Entity Type:Individual
Prefix:MR
First Name:PRESTON
Middle Name:
Last Name:GREEN
Suffix:II
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 VISTA ROJA PL NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1876
Mailing Address - Country:US
Mailing Address - Phone:505-903-0805
Mailing Address - Fax:
Practice Address - Street 1:5900 FOREST HILLS DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4129
Practice Address - Country:US
Practice Address - Phone:505-822-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3086224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant