Provider Demographics
NPI:1467520361
Name:GREEN, TRACEY G (LIC AC)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:G
Last Name:GREEN
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BUENA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:MARBLEHEAD
Mailing Address - State:MA
Mailing Address - Zip Code:01945-1327
Mailing Address - Country:US
Mailing Address - Phone:781-639-5141
Mailing Address - Fax:
Practice Address - Street 1:70 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MARBLEHEAD
Practice Address - State:MA
Practice Address - Zip Code:01945-3042
Practice Address - Country:US
Practice Address - Phone:781-639-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203406171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist