Provider Demographics
NPI:1306089123
Name:GREEN, JOAN S (LMT, CIMI)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:S
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT, CIMI
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:S
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT, CIMI
Mailing Address - Street 1:1524 WILLAMETTE ST STE 202
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-4093
Mailing Address - Country:US
Mailing Address - Phone:541-343-0823
Mailing Address - Fax:
Practice Address - Street 1:1524 WILLAMETTE ST STE 202
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-4093
Practice Address - Country:US
Practice Address - Phone:541-343-0823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-08
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7660172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist