Provider Demographics
NPI:1124549407
Name:GREENE, REVENDA (PT)
Entity Type:Individual
Prefix:DR
First Name:REVENDA
Middle Name:
Last Name:GREENE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 CANVASBACK CT
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-7003
Mailing Address - Country:US
Mailing Address - Phone:301-266-9758
Mailing Address - Fax:
Practice Address - Street 1:1208 CANVASBACK CT
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-7003
Practice Address - Country:US
Practice Address - Phone:301-266-9758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC2024225100000X
MD16414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist