Provider Demographics
NPI:1558635219
Name:GREEN, TIFFANY LOUISE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 WOODLAWN DR
Mailing Address - Street 2:APT. #1
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-4262
Mailing Address - Country:US
Mailing Address - Phone:906-290-2429
Mailing Address - Fax:
Practice Address - Street 1:1501 WOODLAWN DR
Practice Address - Street 2:APT. #1
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-4262
Practice Address - Country:US
Practice Address - Phone:906-290-2429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-28
Last Update Date:2012-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer