Provider Demographics
NPI:1962287219
Name:GREEN, ALYSSA (MS RD LD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:AL
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS RD LD
Mailing Address - Street 1:6307 BLUFF SPRINGS RD APT 524
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-4224
Mailing Address - Country:US
Mailing Address - Phone:804-898-0270
Mailing Address - Fax:
Practice Address - Street 1:1000 GATTIS SCHOOL RD STE 150B
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2566
Practice Address - Country:US
Practice Address - Phone:512-609-0651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88819133V00000X
86295617133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered