Provider Demographics
NPI:1568504389
Name:GREEN, MARIA (LMP)
Entity Type:Individual
Prefix:MS
First Name:MARIA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10511 19TH AVE SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4279
Mailing Address - Country:US
Mailing Address - Phone:425-357-8885
Mailing Address - Fax:425-357-8454
Practice Address - Street 1:10511 19TH AVE SE
Practice Address - Street 2:SUITE B
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-4279
Practice Address - Country:US
Practice Address - Phone:425-357-8885
Practice Address - Fax:425-357-8454
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00018830225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0203682OtherL&I