Provider Demographics
NPI:1942730064
Name:GREEN, ELIZABETH HOLLAND
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HOLLAND
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:GRACE
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9109 LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-3521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9109 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-3521
Practice Address - Country:US
Practice Address - Phone:410-655-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA02480224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant