Provider Demographics
NPI:1568701217
Name:GREEN, DEANTAE (QBA)
Entity Type:Individual
Prefix:
First Name:DEANTAE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:QBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ROSASCHI RD
Mailing Address - Street 2:
Mailing Address - City:YERINGTON
Mailing Address - State:NV
Mailing Address - Zip Code:89447-8722
Mailing Address - Country:US
Mailing Address - Phone:800-507-8662
Mailing Address - Fax:775-463-2379
Practice Address - Street 1:100 ROSASCHI RD
Practice Address - Street 2:
Practice Address - City:YERINGTON
Practice Address - State:NV
Practice Address - Zip Code:89447-8722
Practice Address - Country:US
Practice Address - Phone:800-507-8662
Practice Address - Fax:775-463-2379
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1568549111Medicaid