Provider Demographics
NPI:1306626833
Name:GREEN PEDIATRIC THERAPY
Entity type:Organization
Organization Name:GREEN PEDIATRIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:NATASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:ED S CCC-SLP
Authorized Official - Phone:318-518-1686
Mailing Address - Street 1:4068 EMERALD LAKE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-2735
Mailing Address - Country:US
Mailing Address - Phone:318-518-1686
Mailing Address - Fax:
Practice Address - Street 1:4068 EMERALD LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035
Practice Address - Country:US
Practice Address - Phone:318-518-1686
Practice Address - Fax:470-500-0289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-02
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty