Provider Demographics
NPI:1447583943
Name:GREEN, CHARLA JEAN (LMT)
Entity Type:Individual
Prefix:MS
First Name:CHARLA
Middle Name:JEAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 AMBERLY RD NE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2740
Mailing Address - Country:US
Mailing Address - Phone:321-984-7967
Mailing Address - Fax:
Practice Address - Street 1:601 E STRAWBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4733
Practice Address - Country:US
Practice Address - Phone:321-984-7967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM13301174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist