Provider Demographics
NPI:1841308483
Name:GREEN, MARILYN JO (PT)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:JO
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3655 N LAKESIDE VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:FL
Mailing Address - Zip Code:34465-3328
Mailing Address - Country:US
Mailing Address - Phone:352-746-3472
Mailing Address - Fax:
Practice Address - Street 1:3400 N LECANTO HWY
Practice Address - Street 2:SUITE B
Practice Address - City:BEVERLY HILLS
Practice Address - State:FL
Practice Address - Zip Code:34465-3548
Practice Address - Country:US
Practice Address - Phone:352-527-8489
Practice Address - Fax:352-527-2087
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT8132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist