Provider Demographics
NPI:1871977884
Name:GREEN, HEATHER L (DPT)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N WILLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-9462
Mailing Address - Country:US
Mailing Address - Phone:517-279-7887
Mailing Address - Fax:
Practice Address - Street 1:410 N WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-9462
Practice Address - Country:US
Practice Address - Phone:517-279-7887
Practice Address - Fax:517-279-6527
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501017259225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist