Provider Demographics
NPI:1215188610
Name:GREEN, CANDICAS F (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CANDICAS
Middle Name:F
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 STONEHAM
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109
Mailing Address - Country:US
Mailing Address - Phone:312-692-9960
Mailing Address - Fax:
Practice Address - Street 1:176 STONEHAM RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38109-5720
Practice Address - Country:US
Practice Address - Phone:773-678-5661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-03
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056008433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist