Provider Demographics
NPI:1558567388
Name:GREEN, EMMA L (PT)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 VICTORIA LN
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024
Mailing Address - Country:US
Mailing Address - Phone:323-528-6758
Mailing Address - Fax:
Practice Address - Street 1:780 S ARROYO PKWY
Practice Address - Street 2:SUITES B AND C
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3232
Practice Address - Country:US
Practice Address - Phone:323-528-6758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT333692251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33369OtherSTATE LICENSE