Provider Demographics
NPI:1528193240
Name:GREEN, LISA DIANE (MOMT, MPT, ATC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DIANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MOMT, MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PORTOLA RD
Mailing Address - Street 2:STE. B
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7852
Mailing Address - Country:US
Mailing Address - Phone:650-851-1145
Mailing Address - Fax:650-851-9251
Practice Address - Street 1:150 PORTOLA RD
Practice Address - Street 2:STE. B
Practice Address - City:PORTOLA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94028-7852
Practice Address - Country:US
Practice Address - Phone:650-851-1145
Practice Address - Fax:650-851-9251
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT188002251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic