Provider Demographics
NPI:1578838231
Name:GREEN, ALLISON (MPT)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13140 ASHNUT LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-4302
Mailing Address - Country:US
Mailing Address - Phone:703-390-0545
Mailing Address - Fax:
Practice Address - Street 1:1778 FOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3390
Practice Address - Country:US
Practice Address - Phone:571-926-9398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-14
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006317225100000X
CA22106225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist