Provider Demographics
NPI:1881807105
Name:GREEN, CASSANDRA LOUISE (LMP)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26538 175TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98042-4912
Mailing Address - Country:US
Mailing Address - Phone:253-951-2783
Mailing Address - Fax:
Practice Address - Street 1:13003 SE KENT KANGLEY RD
Practice Address - Street 2:SUITE 110
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7919
Practice Address - Country:US
Practice Address - Phone:253-638-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00021013225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist