Provider Demographics
NPI:1366654402
Name:GREEN, CLATYON
Entity Type:Individual
Prefix:
First Name:CLATYON
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4203 NORTH MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901
Mailing Address - Country:US
Mailing Address - Phone:361-573-2500
Mailing Address - Fax:361-573-2506
Practice Address - Street 1:4203 NORTH MAIN ST.
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901
Practice Address - Country:US
Practice Address - Phone:361-573-2500
Practice Address - Fax:361-573-2506
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51387231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist