Healthcare Provider Details

I. General information

NPI: 1801019088
Provider Name (Legal Business Name): GREEN TREE THERAPEUTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11120 NEW HAMPSHIRE AVE SUITE 506
SILVER SPRING MD
20904-2633
US

IV. Provider business mailing address

11120 NEW HAMPSHIRE AVE SUITE 506
SILVER SPRING MD
20904-2633
US

V. Phone/Fax

Practice location:
  • Phone: 301-592-8200
  • Fax: 301-592-8300
Mailing address:
  • Phone: 301-592-8200
  • Fax: 301-592-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberPT870409
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number21045
License Number StateMD

VIII. Authorized Official

Name: MR. DAVID MICHAEL BULLOCK
Title or Position: FOUNDER & CHAIRMAN
Credential: P.T.
Phone: 301-592-8200