Basic Information
| Provider Information | |||||||||
| NPI: | 1134246648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | THERESE | ||||||||
| MiddleName: | ANNE-COLLINS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1381 PRITCHETT CT | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940245712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6509650140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4655 RUFFNER ST STE 270 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921112276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007876787 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | 5270 | CA | Y | Other Service Providers | Contractor |
ID Information
| ID | Type | State | Issuer | Description | 5270 | 01 | CA | PTA LICENSE | OTHER |