Basic Information
| Provider Information | |||||||||
| NPI: | 1235429093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 903 PAVILION CT STE D | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302536672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049139114 | ||||||||
| FaxNumber: | 4045294729 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 PAVILION CT STE D | ||||||||
| Address2: | |||||||||
| City: | MCDONOUGH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302536672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4049139114 | ||||||||
| FaxNumber: | 4045294729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 02/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 101YP2500X | LPC008640 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.