Provider Demographics
NPI:1316903925
Name:GREEN, RICHARD ALLEN (RPT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALLEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 W SNOQUALMIE RIVER RD NE
Mailing Address - Street 2:
Mailing Address - City:CARNATION
Mailing Address - State:WA
Mailing Address - Zip Code:98014-8103
Mailing Address - Country:US
Mailing Address - Phone:425-588-0620
Mailing Address - Fax:425-200-0026
Practice Address - Street 1:3129 W SNOQUALMIE RIVER RD NE
Practice Address - Street 2:
Practice Address - City:CARNATION
Practice Address - State:WA
Practice Address - Zip Code:98014-8103
Practice Address - Country:US
Practice Address - Phone:425-588-0620
Practice Address - Fax:425-200-0026
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60620424225100000X
CAPT11005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGPT001040Medicaid
WA1316903924Medicaid
CAZZZ19896ZMedicare PIN
CA4524620001Medicare NSC
CAZZZ19895ZMedicare PIN