Provider Demographics
NPI:1093121444
Name:GREEN, CAROLYN M
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
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 1:1247 FITZ HUGH DR SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98513-7736
Mailing Address - Country:US
Mailing Address - Phone:360-561-0137
Mailing Address - Fax:
Practice Address - Street 1:1247 FITZ HUGH DR SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98513-7736
Practice Address - Country:US
Practice Address - Phone:360-561-0137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA751148171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor