Basic Information
| Provider Information | |||||||||
| NPI: | 1356685382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STAFFORD | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 FOREST LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CLEMSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296312621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646542001 | ||||||||
| FaxNumber: | 8003057112 | ||||||||
| Practice Location | |||||||||
| Address1: | 11110 TOM ADAMS DR | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787533354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5128361515 | ||||||||
| FaxNumber: | 8552328604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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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 | 225X00000X | 2729 | SC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 118743 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.