Provider Demographics
NPI:1730149543
Name:GREEN, TICHA MALEEGRAI (DPT)
Entity type:Individual
Prefix:
First Name:TICHA
Middle Name:MALEEGRAI
Last Name:GREEN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TICHA
Other - Middle Name:
Other - Last Name:MALEEGRAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:100 NE NORTHLAKE WAY
Mailing Address - Street 2:STE 200B
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6871
Mailing Address - Country:US
Mailing Address - Phone:206-547-7445
Mailing Address - Fax:206-913-2486
Practice Address - Street 1:11800 NE 128TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-820-0869
Practice Address - Fax:425-820-1745
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009684225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8905374Medicare UPIN
WAG8857612Medicare PIN