Provider Demographics
NPI:1235418609
Name:GREEN, CHAUNCEY (PTA)
Entity Type:Individual
Prefix:
First Name:CHAUNCEY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 WINDOVER RD STE A
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-6064
Mailing Address - Country:US
Mailing Address - Phone:870-336-0238
Mailing Address - Fax:870-336-0239
Practice Address - Street 1:708 WINDOVER RD STE A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-6064
Practice Address - Country:US
Practice Address - Phone:870-336-0238
Practice Address - Fax:870-336-0239
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA#2493225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant