Provider Demographics
NPI:1386790749
Name:GREEN, KRISTA ANN (OTR)
Entity type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 REDBIRD CV
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-1748
Mailing Address - Country:US
Mailing Address - Phone:314-566-0251
Mailing Address - Fax:636-467-5738
Practice Address - Street 1:5433 REDBIRD CV
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052-1748
Practice Address - Country:US
Practice Address - Phone:314-566-0251
Practice Address - Fax:636-467-5738
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031019225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist