Provider Demographics
NPI:1225525108
Name:GREEN, KRISTEN JESSICA (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:JESSICA
Last Name:GREEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N ROCK RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1341
Mailing Address - Country:US
Mailing Address - Phone:316-440-3316
Mailing Address - Fax:888-965-6885
Practice Address - Street 1:3500 N ROCK RD STE 101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1341
Practice Address - Country:US
Practice Address - Phone:316-440-3316
Practice Address - Fax:888-965-6885
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-04882224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KST-04882OtherSTATE OF KANSAS LICENSE