MEDICARE: MS. DARRYLA GREEN LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	T0504	OR

General Provider Information

NPI Number	:	1336319359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DARRYLA GREEN LMFT

Provider Business Mailing Address
First Line	:	4060 NW HOUSTON PL
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97330-1722
Country	:	US
Telephone Number	:	541-757-2084
Fax Number	:

Provider Business Practice Location Address
First Line	:	4060 NW HOUSTON PL
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97330-1722
Country	:	US
Telephone Number	:	541-757-2084
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2008
Last Update Date	:	03/05/2008

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