Provider Demographics
NPI:1114265733
Name:GREEN, WILLIAM THOMAS (LMT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:GREEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19370 COLLINS AVE
Mailing Address - Street 2:UNIT 1010
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-2240
Mailing Address - Country:US
Mailing Address - Phone:305-305-2702
Mailing Address - Fax:
Practice Address - Street 1:19370 COLLINS AVE
Practice Address - Street 2:UNIT 1010
Practice Address - City:SUNNY ISLES BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-2240
Practice Address - Country:US
Practice Address - Phone:305-305-2702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA67064225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist