Individual
BREANNA PAULINE GREEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3023 S FORT AVE STE B, SPRINGFIELD, MO 65807-4217
(417) 890-4656
(417) 708-0889
Mailing address
3023 S FORT AVE STE B, SPRINGFIELD, MO 65807-4217
(417) 890-4656
(417) 708-0889
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
2019000985
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2019000985
MO STATE LICENSE
MO
Enumeration date
01/13/2019
Last updated
01/13/2019
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