Provider Demographics
NPI:1457627796
Name:GREENWELL, CONSTANCE S (COTA)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:S
Last Name:GREENWELL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 PINDELL AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2322
Mailing Address - Country:US
Mailing Address - Phone:502-216-3789
Mailing Address - Fax:
Practice Address - Street 1:2620 PINDELL AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-2322
Practice Address - Country:US
Practice Address - Phone:502-216-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA3658224Z00000X
NM2864224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant