Provider Demographics
NPI:1255688586
Name:GREEN, KATIE (DPT)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 S GREEN BAY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:MT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:708-283-9971
Practice Address - Street 1:1532 S GREEN BAY RD
Practice Address - Street 2:STE 200
Practice Address - City:MT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4468
Practice Address - Country:US
Practice Address - Phone:262-321-0240
Practice Address - Fax:708-283-9971
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-019219225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist