Provider Demographics
NPI:1013106046
Name:GREEN, REBECCA A (DC, DACBSP)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:DC, DACBSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1632
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-8132
Mailing Address - Country:US
Mailing Address - Phone:860-537-8900
Mailing Address - Fax:860-537-8868
Practice Address - Street 1:121 BROADWAY ST
Practice Address - Street 2:SUITE 2
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1052
Practice Address - Country:US
Practice Address - Phone:860-537-8900
Practice Address - Fax:860-537-8868
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001023111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050001023CT04OtherANTHEM BCBS
CTCT01023OtherHEALTH NET
CT3984974OtherAETNA
CT3984974OtherAETNA