Provider Demographics
NPI:1548426034
Name:GREEN, LYNDAL (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LYNDAL
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CHRISTOPHER CV
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-2166
Mailing Address - Country:US
Mailing Address - Phone:501-227-0083
Mailing Address - Fax:
Practice Address - Street 1:11517 KANIS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3724
Practice Address - Country:US
Practice Address - Phone:501-993-8707
Practice Address - Fax:501-223-8075
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR335171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116021721Medicaid