Provider Demographics
NPI:1689172876
Name:JOHNSTON GREEN, ANDREA LEE (ATC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEE
Last Name:JOHNSTON 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 1:16208 REMUDA TRL
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-9349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16208 REMUDA TRL
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-9349
Practice Address - Country:US
Practice Address - Phone:512-619-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer