Provider Demographics
NPI:1568867117
Name:GREENE, MICHAEL (CMT, CMMP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GREENE
Suffix:
Gender:M
Credentials:CMT, CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 W NEES AVE APT 143
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-6864
Mailing Address - Country:US
Mailing Address - Phone:559-476-6491
Mailing Address - Fax:
Practice Address - Street 1:336 W BEDFORD AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-6185
Practice Address - Country:US
Practice Address - Phone:559-476-6491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61093225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist