Healthcare Provider Details

I. General information

NPI: 1376246470
Provider Name (Legal Business Name): LISA GREEN PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2023
Last Update Date: 03/27/2023
Certification Date: 03/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 PORTOLA RD
PORTOLA VALLEY CA
94028-7825
US

IV. Provider business mailing address

108 PORTOLA RD
PORTOLA VALLEY CA
94028-7825
US

V. Phone/Fax

Practice location:
  • Phone: 650-851-1145
  • Fax: 650-851-9251
Mailing address:
  • Phone: 650-851-1145
  • Fax: 650-851-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA GREEN
Title or Position: PRESIDENT
Credential: PT, MOMT, MPT, ATC
Phone: 650-851-1145