Provider Demographics
NPI:1558401224
Name:GREEN, KRISTY MARIE (MPT)
Entity Type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11416 WINDSOR ROAD
Mailing Address - Street 2:
Mailing Address - City:IJAMSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21754
Mailing Address - Country:US
Mailing Address - Phone:301-831-6147
Mailing Address - Fax:
Practice Address - Street 1:8885 CENTRE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045
Practice Address - Country:US
Practice Address - Phone:410-730-1275
Practice Address - Fax:410-740-2497
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21812225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist