Provider Demographics
NPI:1164406377
Name:GREEN, GLYNISS CLAUDETTE (PT, DPT, OCS)
Entity Type:Individual
Prefix:
First Name:GLYNISS
Middle Name:CLAUDETTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT, DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23100 EUCALYPTUS AVE STE C
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5439
Mailing Address - Country:US
Mailing Address - Phone:951-379-1500
Mailing Address - Fax:951-379-1501
Practice Address - Street 1:23100 EUCALYPTUS AVE STE C
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5439
Practice Address - Country:US
Practice Address - Phone:951-379-1500
Practice Address - Fax:951-379-1501
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA226502251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA650024810OtherRR MEDICARE
WA0175118OtherWA DEPT OF LABOR
CA650024810OtherRR MEDICARE