Provider Demographics
NPI:1336362029
Name:GREEN, BLAIR (MPT)
Entity type:Individual
Prefix:
First Name:BLAIR
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5538 TRACE VIEWS DR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1436
Mailing Address - Country:US
Mailing Address - Phone:770-500-3848
Mailing Address - Fax:
Practice Address - Street 1:3300 NORTHEAST EXPY NE
Practice Address - Street 2:BUILDING 8, SUITE C
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-3932
Practice Address - Country:US
Practice Address - Phone:770-500-3848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006847225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist