Provider Demographics
NPI:1982825345
Name:GREEN, WANDA (OTR)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 TIMBERLINE DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1963
Mailing Address - Country:US
Mailing Address - Phone:757-838-3532
Mailing Address - Fax:
Practice Address - Street 1:119 BULIFANTS BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-5709
Practice Address - Country:US
Practice Address - Phone:757-564-1650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119002203225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist