Provider Demographics
NPI:1174738108
Name:GREEN, STEVEN
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEVEN
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:15 ELK RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:WA
Mailing Address - Zip Code:98541-9255
Mailing Address - Country:US
Mailing Address - Phone:360-789-8821
Mailing Address - Fax:
Practice Address - Street 1:100 RUBY ST SE
Practice Address - Street 2:SUITE F
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98501-6723
Practice Address - Country:US
Practice Address - Phone:360-943-4797
Practice Address - Fax:360-709-0542
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00013794225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist