Provider Demographics
NPI:1366779258
Name:GREEN, ELISHEVA (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:ELISHEVA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7730 LAGO DEL MAR DR
Mailing Address - Street 2:UNIT 606
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-4907
Mailing Address - Country:US
Mailing Address - Phone:917-670-1336
Mailing Address - Fax:
Practice Address - Street 1:7730 LAGO DEL MAR DR
Practice Address - Street 2:UNIT 606
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-4907
Practice Address - Country:US
Practice Address - Phone:917-670-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12440225X00000X
NY013584-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist