Basic Information
| Provider Information | |||||||||
| NPI: | 1063823730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | ALEXIS | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13904 N DALE MABRY HWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139082020 | ||||||||
| FaxNumber: | 8139082133 | ||||||||
| Practice Location | |||||||||
| Address1: | 13904 N DALE MABRY HWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139082020 | ||||||||
| FaxNumber: | 8139082133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2014 | ||||||||
| LastUpdateDate: | 12/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AZ663 | FL | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | AY1892 | FL | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.