Provider Demographics
NPI:1952672008
Name:GREEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 W SYBELIA AVE
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3920 ROSEWOOD WAY
Practice Address - Street 2:REHAB DEPARTMENT
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-1033
Practice Address - Country:US
Practice Address - Phone:407-298-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA11983224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant