1770679060 NPI number — SARAH SUE GREENE OTR/L

Table of content: SARAH SUE GREENE OTR/L (NPI 1770679060)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770679060 NPI number — SARAH SUE GREENE OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREENE
Provider First Name:
SARAH
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOLTZ
Provider Other First Name:
SARAH
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR/L
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770679060
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2683 LEYLAND TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-3571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-207-6087
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 ENLOE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUDSON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54016-8173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-386-2128
Provider Business Practice Location Address Fax Number:
715-386-6119
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  4201 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40877300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3582973 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 15665 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6404786 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 641671046996 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 97G20GR . This is a "BCBS MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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