Provider Demographics
NPI:1023573029
Name:GREEN, MYRON WESTLEY (OTR)
Entity type:Individual
Prefix:MR
First Name:MYRON
Middle Name:WESTLEY
Last Name:GREEN
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 PINE GROVE DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2369
Mailing Address - Country:US
Mailing Address - Phone:404-234-3074
Mailing Address - Fax:
Practice Address - Street 1:955 INTERSTATE RIDGE DR UNIT E
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7051
Practice Address - Country:US
Practice Address - Phone:678-936-8695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist