Provider Demographics
NPI:1093176448
Name:GREEN, DEANNE (ATC)
Entity Type:Individual
Prefix:MS
First Name:DEANNE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7330 SHADELAND STA
Mailing Address - Street 2:SUITE 150
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3957
Mailing Address - Country:US
Mailing Address - Phone:317-621-7728
Mailing Address - Fax:
Practice Address - Street 1:7330 SHADELAND STA
Practice Address - Street 2:SUITE 150
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-3957
Practice Address - Country:US
Practice Address - Phone:317-621-7728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002031A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer