Provider Demographics
NPI:1699249912
Name:GREEN, LINDA KIM (PTA)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:KIM
Last Name:GREEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:LINDA
Other - Middle Name:KIM
Other - Last Name:GROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:5625 SUGAR CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571-2724
Mailing Address - Country:US
Mailing Address - Phone:281-382-0013
Mailing Address - Fax:
Practice Address - Street 1:5800 W BAKER RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77520-1618
Practice Address - Country:US
Practice Address - Phone:281-382-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-21
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2007373225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2007373OtherPHYSCIAL THERAPIST ASSISTANT