Provider Demographics
NPI:1528146545
Name:GREEN, MARTHA LOUISE (LAC)
Entity type:Individual
Prefix:MISS
First Name:MARTHA
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 SE 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-4011
Mailing Address - Country:US
Mailing Address - Phone:971-570-1544
Mailing Address - Fax:
Practice Address - Street 1:2538 NE BROADWAY ST STE C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1872
Practice Address - Country:US
Practice Address - Phone:503-282-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00651171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist