Provider Demographics
NPI:1295215028
Name:GREENE, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
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 1:120 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:FERRIS
Mailing Address - State:TX
Mailing Address - Zip Code:75125-2309
Mailing Address - Country:US
Mailing Address - Phone:214-458-5743
Mailing Address - Fax:
Practice Address - Street 1:3617 OHARE DRIVE
Practice Address - Street 2:
Practice Address - City:MEQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:214-458-5743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209167224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant