Provider Demographics
NPI:1114658119
Name:GREENE, HAILEY VERONIKA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:VERONIKA
Last Name:GREENE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 PATTON AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3041
Mailing Address - Country:US
Mailing Address - Phone:318-880-3228
Mailing Address - Fax:
Practice Address - Street 1:266 PATTON AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-3041
Practice Address - Country:US
Practice Address - Phone:318-880-3228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11188225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist