Provider Demographics
NPI:1467887265
Name:GREEN, TIMOTHY J (MA CCC/SLP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 WOLCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-1528
Mailing Address - Country:US
Mailing Address - Phone:781-245-5992
Mailing Address - Fax:
Practice Address - Street 1:6 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-1528
Practice Address - Country:US
Practice Address - Phone:781-245-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA565235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist