Basic Information
| Provider Information | |||||||||
| NPI: | 1225525108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | JESSICA | ||||||||
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| Credential: | COTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 N ROCK RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672261341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164403316 | ||||||||
| FaxNumber: | 8889656885 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 N ROCK RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672261341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3164403316 | ||||||||
| FaxNumber: | 8889656885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2018 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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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 | 224Z00000X | T-04882 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | T-04882 | 01 | KS | STATE OF KANSAS LICENSE | OTHER |