Provider Demographics
NPI:1376213298
Name:GREEN, HAYDEN LEE (PTA)
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:LEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:HAYDEN
Other - Middle Name:LEE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:231 34TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-4843
Mailing Address - Country:US
Mailing Address - Phone:405-593-8353
Mailing Address - Fax:888-558-6690
Practice Address - Street 1:231 34TH AVE SW
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4843
Practice Address - Country:US
Practice Address - Phone:405-593-8353
Practice Address - Fax:888-558-6690
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2758225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant