Provider Demographics
NPI:1659751055
Name:GREEN, RACHELLE
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 CHERRY ST
Mailing Address - Street 2:MS 21041
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1320
Mailing Address - Country:US
Mailing Address - Phone:215-571-4287
Mailing Address - Fax:215-571-4640
Practice Address - Street 1:1601 CHERRY ST
Practice Address - Street 2:MS 21041
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1320
Practice Address - Country:US
Practice Address - Phone:215-571-4287
Practice Address - Fax:215-571-4640
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATPT021627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist