Provider Demographics
NPI:1801817218
Name:GREEN, DIANE (PT)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MADRONE AVE
Mailing Address - Street 2:
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-1080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 LARKSPUR LANDING CIR
Practice Address - Street 2:
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939-1834
Practice Address - Country:US
Practice Address - Phone:415-461-8233
Practice Address - Fax:415-461-6412
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist