Provider Demographics
NPI:1750446464
Name:GREEN, LAURIE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1079 N VULCAN AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1723
Mailing Address - Country:US
Mailing Address - Phone:760-445-3408
Mailing Address - Fax:760-456-9739
Practice Address - Street 1:1079 N VULCAN AVE
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1723
Practice Address - Country:US
Practice Address - Phone:760-445-3408
Practice Address - Fax:760-456-9739
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist