Provider Demographics
NPI:1780938837
Name:GREEN, BRIAN CHARLES (OT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:CHARLES
Last Name:GREEN
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 CANDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8253
Mailing Address - Country:US
Mailing Address - Phone:479-263-1268
Mailing Address - Fax:
Practice Address - Street 1:1513 S DIXIELAND RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-4935
Practice Address - Country:US
Practice Address - Phone:479-636-5841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-28
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1586225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist