Provider Demographics
NPI:1366964462
Name:GREEN, KENNETH WALTER (LMT, OM)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WALTER
Last Name:GREEN
Suffix:
Gender:M
Credentials:LMT, OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 ROCKMOOR DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-8983
Mailing Address - Country:US
Mailing Address - Phone:512-609-9188
Mailing Address - Fax:
Practice Address - Street 1:307 ROCKMOOR DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-8983
Practice Address - Country:US
Practice Address - Phone:512-609-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT122578225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist