Provider Demographics
NPI:1972096881
Name:GREEN, MELINDA POTEET (NBCOT, COTA)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:POTEET
Last Name:GREEN
Suffix:
Gender:F
Credentials:NBCOT, COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503
Mailing Address - Street 2:
Mailing Address - City:HIGH ROLLS MOUNTAIN PARK
Mailing Address - State:NM
Mailing Address - Zip Code:88325-0503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 503
Practice Address - Street 2:
Practice Address - City:HIGH ROLLS MOUNTAIN PARK
Practice Address - State:NM
Practice Address - Zip Code:88325-0503
Practice Address - Country:US
Practice Address - Phone:979-820-0562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3600224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant