Provider Demographics
NPI:1104456953
Name:GREEN, LINDSAY MICHELE (OTA)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:MICHELE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10450 N MAGNOLIA AVE APT R2
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-1727
Mailing Address - Country:US
Mailing Address - Phone:619-366-9645
Mailing Address - Fax:
Practice Address - Street 1:240 S MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-4524
Practice Address - Country:US
Practice Address - Phone:619-631-7222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4280224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant