Provider Demographics
NPI:1851581151
Name:KIM GREEN OCCUPATIONAL THERAPY, PC
Entity Type:Organization
Organization Name:KIM GREEN OCCUPATIONAL THERAPY, PC
Other - Org Name:GREEN REHABILITATION & INJURY MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:C
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:315-637-0035
Mailing Address - Street 1:104 CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-2045
Mailing Address - Country:US
Mailing Address - Phone:315-637-0035
Mailing Address - Fax:315-637-1335
Practice Address - Street 1:104 CLINTON ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-2045
Practice Address - Country:US
Practice Address - Phone:315-637-0035
Practice Address - Fax:315-637-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006484225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC6755Medicare UPIN
NYAA0934Medicare PIN