Basic Information
| Provider Information | |||||||||
| NPI: | 1528580099 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15226 GOODTIME CT | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460321037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179374317 | ||||||||
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| Practice Location | |||||||||
| Address1: | 118 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460322923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175773103 | ||||||||
| FaxNumber: | 3172003965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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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 | 225200000X | 060003159A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 060003159A | 01 | IN | INDIANA PROFESSIONAL LICENSING AGENCY | OTHER |