Provider Demographics
NPI:1528580099
Name:GREEN, PATRICIA LYNN (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:LYNN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15226 GOODTIME CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1037
Mailing Address - Country:US
Mailing Address - Phone:317-937-4317
Mailing Address - Fax:
Practice Address - Street 1:118 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2923
Practice Address - Country:US
Practice Address - Phone:317-577-3103
Practice Address - Fax:317-200-3965
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN060003159A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN060003159AOtherINDIANA PROFESSIONAL LICENSING AGENCY