Provider Demographics
NPI:1275637266
Name:GREEN, MARY ANN (COTA VRC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:COTA VRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SW MARLOW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5185
Mailing Address - Country:US
Mailing Address - Phone:503-292-0765
Mailing Address - Fax:503-292-5208
Practice Address - Street 1:1815 SW MARLOW
Practice Address - Street 2:SUITE 110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5185
Practice Address - Country:US
Practice Address - Phone:503-292-0765
Practice Address - Fax:503-292-5208
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5707224Z00000X
ORAM0140225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor