Provider Demographics
NPI:1740778497
Name:GREEN, CAROLYN RUTH (PTA)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:RUTH
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:CAROLYN
Other - Middle Name:RUTH
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:18920 42ND AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2804
Mailing Address - Country:US
Mailing Address - Phone:917-864-4196
Mailing Address - Fax:
Practice Address - Street 1:5 DAKOTA DR STE 200
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1109
Practice Address - Country:US
Practice Address - Phone:631-752-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008819225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant