Provider Demographics
NPI:1750504015
Name:GREEN, HEIDI LAUREN (MSPT)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:LAUREN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 WASHINGTON PARK
Mailing Address - Street 2:#3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-4007
Mailing Address - Country:US
Mailing Address - Phone:914-980-4136
Mailing Address - Fax:
Practice Address - Street 1:124 E 40TH ST
Practice Address - Street 2:SUITE 1002
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-1723
Practice Address - Country:US
Practice Address - Phone:212-986-4161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021516225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist