Provider Demographics
NPI:1578548657
Name:GREENE, LAURA WEINER (OT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:WEINER
Last Name:GREENE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 N EL CAMINO REAL
Mailing Address - Street 2:STE 210
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-2811
Mailing Address - Country:US
Mailing Address - Phone:760-634-0248
Mailing Address - Fax:760-634-1782
Practice Address - Street 1:317 N EL CAMINO REAL
Practice Address - Street 2:#210
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-2811
Practice Address - Country:US
Practice Address - Phone:760-634-0248
Practice Address - Fax:760-364-1782
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 1536225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOT1536AOtherMEDICARE PTAN