Provider Demographics
NPI:1356685382
Name:GREEN, KRISTINA LYNNE (OT)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:LYNNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MS
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:STAFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:501 FOREST LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLEMSON
Mailing Address - State:SC
Mailing Address - Zip Code:29631-2621
Mailing Address - Country:US
Mailing Address - Phone:864-654-2001
Mailing Address - Fax:800-305-7112
Practice Address - Street 1:11110 TOM ADAMS DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-3354
Practice Address - Country:US
Practice Address - Phone:512-836-1515
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2729225X00000X
TX118743225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist