Provider Demographics
NPI:1184264392
Name:GREEN, NATALIE LEA (COTA/L)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:LEA
Last Name:GREEN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:NATALIE
Other - Middle Name:LEA
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 N AVON ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-5829
Mailing Address - Country:US
Mailing Address - Phone:563-210-7471
Mailing Address - Fax:
Practice Address - Street 1:511 N AVON ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-5829
Practice Address - Country:US
Practice Address - Phone:563-210-7471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057004594224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant