Provider Demographics
NPI:1689901803
Name:GREEN, AMBROSE JR (MOT)
Entity Type:Individual
Prefix:MR
First Name:AMBROSE
Middle Name:
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35431 AVALON ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1724
Mailing Address - Country:US
Mailing Address - Phone:734-262-4576
Mailing Address - Fax:734-721-7009
Practice Address - Street 1:35431 AVALON
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174
Practice Address - Country:US
Practice Address - Phone:734-262-4576
Practice Address - Fax:734-721-7009
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007262225X00000X
AL2776225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist