Basic Information
| Provider Information | |||||||||
| NPI: | 1912423492 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | GREEN | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5465 BRAESVALLEY DR APT 530 | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770963124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256205815 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8001 S US HIGHWAY 75 | ||||||||
| Address2: | |||||||||
| City: | SHERMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750905707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035321400 | ||||||||
| FaxNumber: | 9035326575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2017 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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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 | 224Z00000X | 213314 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.