Provider Demographics
NPI:1881702280
Name:GREEN, KIMBERLY CANNON (OTR/C)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:CANNON
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WEST SENCEA ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104
Mailing Address - Country:US
Mailing Address - Phone:315-682-0032
Mailing Address - Fax:315-682-2715
Practice Address - Street 1:102 WEST SENCEA ST
Practice Address - Street 2:SUITE 206
Practice Address - City:MANLIUS
Practice Address - State:NY
Practice Address - Zip Code:13104
Practice Address - Country:US
Practice Address - Phone:315-682-0032
Practice Address - Fax:315-682-2715
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006484225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02175313Medicaid
NY02175313Medicaid
CC6755Medicare UPIN