Provider Demographics
NPI:1053905737
Name:GREEN, SHEROLYN (OTR/L)
Entity type:Individual
Prefix:
First Name:SHEROLYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3970 SHENANDOAH DR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3329
Mailing Address - Country:US
Mailing Address - Phone:858-205-3063
Mailing Address - Fax:
Practice Address - Street 1:3970 SHENANDOAH DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-3329
Practice Address - Country:US
Practice Address - Phone:858-205-3063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12320225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12320Medicaid