Provider Demographics
NPI:1275861049
Name:GREEN, WARREN M (COTA/L)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15241 SONOMA DR
Mailing Address - Street 2:206
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-7329
Mailing Address - Country:US
Mailing Address - Phone:781-718-2669
Mailing Address - Fax:
Practice Address - Street 1:15241 SONOMA DR
Practice Address - Street 2:206
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-7329
Practice Address - Country:US
Practice Address - Phone:781-718-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-06
Last Update Date:2009-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA10994224Z00000X
MA2071224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant