Provider Demographics
NPI:1912558768
Name:GREEN, MATTHEW S
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20445 EMERALD PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-6031
Mailing Address - Country:US
Mailing Address - Phone:440-554-9343
Mailing Address - Fax:
Practice Address - Street 1:20445 EMERALD PKWY STE 140
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-6031
Practice Address - Country:US
Practice Address - Phone:440-554-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16205225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist