Provider Demographics
NPI:1134336787
Name:GREEN, TINA KAY (OTR)
Entity type:Individual
Prefix:MISS
First Name:TINA
Middle Name:KAY
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 1:71 FAITH LN
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-8612
Mailing Address - Country:US
Mailing Address - Phone:270-395-0602
Mailing Address - Fax:
Practice Address - Street 1:803 POPLAR ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-2432
Practice Address - Country:US
Practice Address - Phone:270-762-1771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2735225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist