Provider Demographics
NPI:1235408485
Name:GREEN, MARIA P (COTA)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:P
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 1:17 CHIMNEY LANE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-357-4739
Mailing Address - Fax:
Practice Address - Street 1:17 CHIMNEY LANE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-357-4739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003289-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor