Provider Demographics
NPI:1407017122
Name:GREEN, ELIZABETH WALLENBORN (MA CCCLA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:WALLENBORN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA CCCLA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 TONEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1228
Mailing Address - Country:US
Mailing Address - Phone:256-883-5865
Mailing Address - Fax:
Practice Address - Street 1:3000 JOHNSON ROAD SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-5847
Practice Address - Country:US
Practice Address - Phone:256-650-1701
Practice Address - Fax:256-650-1780
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL671A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist