Provider Demographics
NPI:1124538004
Name:GREEN, AMY J (RPT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E NORTH ST STE C
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1188
Mailing Address - Country:US
Mailing Address - Phone:815-802-7503
Mailing Address - Fax:815-802-7514
Practice Address - Street 1:535 E NORTH ST STE C
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1188
Practice Address - Country:US
Practice Address - Phone:815-802-7503
Practice Address - Fax:815-802-7514
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.006337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist