Provider Demographics
NPI:1801019088
Name:GREEN TREE THERAPEUTICS LLC
Entity type:Organization
Organization Name:GREEN TREE THERAPEUTICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:301-592-8200
Mailing Address - Street 1:11120 NEW HAMPSHIRE AVE
Mailing Address - Street 2:SUITE 506
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2633
Mailing Address - Country:US
Mailing Address - Phone:301-592-8200
Mailing Address - Fax:301-592-8300
Practice Address - Street 1:11120 NEW HAMPSHIRE AVE
Practice Address - Street 2:SUITE 506
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-2633
Practice Address - Country:US
Practice Address - Phone:301-592-8200
Practice Address - Fax:301-592-8300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPT870409225400000X
MD21045225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCG02601Medicare PIN