Provider Demographics
NPI:1073100269
Name:GREEN, FABIONE
Entity Type:Individual
Prefix:
First Name:FABIONE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20818 44TH AVE W STE 270
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-7709
Mailing Address - Country:US
Mailing Address - Phone:425-673-6911
Mailing Address - Fax:425-712-0641
Practice Address - Street 1:500 SW 7TH ST STE 500
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2983
Practice Address - Country:US
Practice Address - Phone:425-687-7370
Practice Address - Fax:425-712-0641
Is Sole Proprietor?:No
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACB61127642106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician