Provider Demographics
NPI:1932283116
Name:GREENE, STEPHANIE CAROL (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:CAROL
Last Name:GREENE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1619 OSBORNE ST
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-2927
Mailing Address - Country:US
Mailing Address - Phone:731-824-2290
Mailing Address - Fax:
Practice Address - Street 1:2031 AVONDALE ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-1810
Practice Address - Country:US
Practice Address - Phone:731-784-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOTA 0677224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant