Provider Demographics
NPI:1184757908
Name:GREENE, ROBERT D (PTA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:D
Last Name:GREENE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3193 OAKPARK DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-7957
Mailing Address - Country:US
Mailing Address - Phone:863-607-6065
Mailing Address - Fax:863-607-6065
Practice Address - Street 1:8800 GRAND OAK CIR
Practice Address - Street 2:SUITE 450
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33637-2006
Practice Address - Country:US
Practice Address - Phone:813-558-6505
Practice Address - Fax:813-975-1016
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA14096225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant