Provider Demographics
NPI:1902183783
Name:GREEN, AMANDA JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 SHAMROCK DR
Mailing Address - Street 2:SUITES 100-102
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-7325
Mailing Address - Country:US
Mailing Address - Phone:812-475-3494
Mailing Address - Fax:812-475-3494
Practice Address - Street 1:4900 SHAMROCK DR
Practice Address - Street 2:SUITES 100-102
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-7325
Practice Address - Country:US
Practice Address - Phone:812-475-3494
Practice Address - Fax:812-475-3494
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06003439A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant