Provider Demographics
NPI:1447858774
Name:GREEN, MARLYN DAZA (HIS)
Entity type:Individual
Prefix:
First Name:MARLYN
Middle Name:DAZA
Last Name:GREEN
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7319 CREEK WOOD PL NE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98311-8208
Mailing Address - Country:US
Mailing Address - Phone:360-731-5650
Mailing Address - Fax:
Practice Address - Street 1:9576 RIDGETOP BLVD NW STE 103
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8554
Practice Address - Country:US
Practice Address - Phone:360-551-4800
Practice Address - Fax:360-551-4801
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA61074569237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist