Provider Demographics
NPI:1093103301
Name:GREEN, KATHERINE (PTA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 NE 61ST TER
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64119-1982
Mailing Address - Country:US
Mailing Address - Phone:951-545-4013
Mailing Address - Fax:
Practice Address - Street 1:810 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64050-4025
Practice Address - Country:US
Practice Address - Phone:951-545-4013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011037565225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant