Provider Demographics
NPI:1700661949
Name:GREEN, OWEN (PT, DPT)
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 FORESTVIEW CT
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1445
Mailing Address - Country:US
Mailing Address - Phone:716-939-0099
Mailing Address - Fax:
Practice Address - Street 1:2075 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14223-1425
Practice Address - Country:US
Practice Address - Phone:716-803-8220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist