Provider Demographics
NPI:1487047783
Name:GREEN, MARTY JOSEPH (PTA)
Entity type:Individual
Prefix:MR
First Name:MARTY
Middle Name:JOSEPH
Last Name:GREEN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 NURSING HOME RD
Mailing Address - Street 2:
Mailing Address - City:OWENSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65066-2844
Mailing Address - Country:US
Mailing Address - Phone:573-437-5510
Mailing Address - Fax:
Practice Address - Street 1:1910 NURSING HOME RD
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066-2844
Practice Address - Country:US
Practice Address - Phone:573-437-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008020867225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant