Healthcare Provider Details

I. General information

NPI: 1407017122
Provider Name (Legal Business Name): ELIZABETH WALLENBORN GREEN MA CCCLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 JOHNSON ROAD SW
HUNTSVILLE AL
35805-5847
US

IV. Provider business mailing address

1305 TONEY DRIVE
HUNTSVILLE AL
35802-1228
US

V. Phone/Fax

Practice location:
  • Phone: 256-650-1701
  • Fax: 256-650-1780
Mailing address:
  • Phone: 256-883-5865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number671A
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: