Provider Demographics
NPI:1851889539
Name:GREEN, WILLIAM SHELTON (ATC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SHELTON
Last Name:GREEN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:WILLIE
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1055 RICELAND CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075
Mailing Address - Country:US
Mailing Address - Phone:770-617-1338
Mailing Address - Fax:
Practice Address - Street 1:1055 RICELAND CT
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075
Practice Address - Country:US
Practice Address - Phone:770-617-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA900893476OtherUNITED HEALTHCARE