Provider Demographics
NPI:1497296297
Name:GREEN, STANLEY (SLP)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10411 NARROWS DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98303-8664
Mailing Address - Country:US
Mailing Address - Phone:253-223-9759
Mailing Address - Fax:
Practice Address - Street 1:10411 NARROWS DR
Practice Address - Street 2:
Practice Address - City:ANDERSON ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98303-8664
Practice Address - Country:US
Practice Address - Phone:253-223-9759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60398665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist