Provider Demographics
NPI:1457476335
Name:GREEN, TAVEAN GRANT (ATP, OTRL)
Entity Type:Individual
Prefix:MR
First Name:TAVEAN
Middle Name:GRANT
Last Name:GREEN
Suffix:
Gender:M
Credentials:ATP, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2777 ENTRADA CIR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-4231
Mailing Address - Country:US
Mailing Address - Phone:925-354-7901
Mailing Address - Fax:
Practice Address - Street 1:200 MUIR RD
Practice Address - Street 2:KAISER HOME HEALTH DEPT - HACIENDA BLDG
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4614
Practice Address - Country:US
Practice Address - Phone:925-313-4835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT2830225X00000X, 246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other