Provider Demographics
NPI:1790029478
Name:GREEN, DEYANNA EVANGELA (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:DEYANNA
Middle Name:EVANGELA
Last Name:GREEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 S STADIUM DR
Mailing Address - Street 2:APT 27
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2133
Mailing Address - Country:US
Mailing Address - Phone:770-899-3872
Mailing Address - Fax:
Practice Address - Street 1:4600 S STADIUM DR
Practice Address - Street 2:APT 27
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2133
Practice Address - Country:US
Practice Address - Phone:770-899-3872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001312224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant