Provider Demographics
NPI:1487747184
Name:GREEN, SUSAN TATE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:TATE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 MAIN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6057
Mailing Address - Country:US
Mailing Address - Phone:901-497-8665
Mailing Address - Fax:
Practice Address - Street 1:520 E MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-3236
Practice Address - Country:US
Practice Address - Phone:541-883-4754
Practice Address - Fax:541-883-4775
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16820235Z00000X
TN1614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist