Provider Demographics
NPI:1356125785
Name:GREEN, TANYA RENAE (MT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RENAE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:CLARKDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:86324-3347
Mailing Address - Country:US
Mailing Address - Phone:928-399-8390
Mailing Address - Fax:
Practice Address - Street 1:3192 N WINDSONG DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2239
Practice Address - Country:US
Practice Address - Phone:928-288-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28466225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist