Provider Demographics
NPI:1396920286
Name:GREEN, LA-WAN ANTONETTE (LMT)
Entity type:Individual
Prefix:MRS
First Name:LA-WAN
Middle Name:ANTONETTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2931 E PEPPERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75134-2034
Mailing Address - Country:US
Mailing Address - Phone:972-227-0180
Mailing Address - Fax:
Practice Address - Street 1:2931 E PEPPERIDGE DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75134-2034
Practice Address - Country:US
Practice Address - Phone:972-227-0180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT103655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist