Provider Demographics
NPI:1245609312
Name:GREENE, ELIZABETH ASHLEY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5251 JOT EM DOWN RD
Mailing Address - Street 2:
Mailing Address - City:DANIELSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30633-2037
Mailing Address - Country:US
Mailing Address - Phone:706-302-5717
Mailing Address - Fax:
Practice Address - Street 1:5251 JOT EM DOWN RD
Practice Address - Street 2:
Practice Address - City:DANIELSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30633-2037
Practice Address - Country:US
Practice Address - Phone:706-302-5717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006261225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOT006261OtherSTATE LICENSE