Provider Demographics
NPI:1871195198
Name:GREEN, BETHANY GRACE (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:GRACE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 MARTIN RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5542
Mailing Address - Country:US
Mailing Address - Phone:678-679-1261
Mailing Address - Fax:678-250-9010
Practice Address - Street 1:4640 MARTIN RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-5542
Practice Address - Country:US
Practice Address - Phone:678-679-1261
Practice Address - Fax:678-250-9010
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist