Provider Demographics
NPI:1508527011
Name:GREEN, MINDY (PTA)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:
Other - Last Name:SAULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16208 E 32ND ST S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-2733
Mailing Address - Country:US
Mailing Address - Phone:573-480-5320
Mailing Address - Fax:
Practice Address - Street 1:930 NE DUNCAN RD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014-2173
Practice Address - Country:US
Practice Address - Phone:816-229-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2105038432225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant