Provider Demographics
NPI:1225072382
Name:GREEN, ALISHA RENEE (OTR L)
Entity Type:Individual
Prefix:MRS
First Name:ALISHA
Middle Name:RENEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 W IVANHOE ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-1845
Mailing Address - Country:US
Mailing Address - Phone:480-893-1045
Mailing Address - Fax:
Practice Address - Street 1:5800 W IVANHOE ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-1845
Practice Address - Country:US
Practice Address - Phone:480-893-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2739174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ628108Medicare UPIN