Healthcare Provider Details

I. General information

NPI: 1356947139
Provider Name (Legal Business Name): ALLISON GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2020
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 EL PASO RD
RUIDOSO NM
88345-6033
US

IV. Provider business mailing address

143 EL PASO RD
RUIDOSO NM
88345-6033
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-2368
  • Fax:
Mailing address:
  • Phone: 575-257-2368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: