Provider Demographics
NPI:1821332388
Name:GREEN, THERESA LYNN (COTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:GREEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2349 MAUVE TERACE
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34286
Mailing Address - Country:US
Mailing Address - Phone:603-714-4475
Mailing Address - Fax:
Practice Address - Street 1:30 COLBY CT
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6426
Practice Address - Country:US
Practice Address - Phone:603-296-3705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16472224Z00000X
NH0440224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant