Provider Demographics
NPI:1609407618
Name:GREEN, LARYSSA (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:LARYSSA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-1104
Mailing Address - Country:US
Mailing Address - Phone:718-594-5815
Mailing Address - Fax:
Practice Address - Street 1:391 MONROE ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-1104
Practice Address - Country:US
Practice Address - Phone:718-594-5815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024289225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist