Provider Demographics
NPI:1386079911
Name:GREEN, CARLA M (LMT)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 STRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-5715
Mailing Address - Country:US
Mailing Address - Phone:406-721-4955
Mailing Address - Fax:
Practice Address - Street 1:370 STRAND AVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-5715
Practice Address - Country:US
Practice Address - Phone:406-721-4955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-13
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT612225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist