Provider Demographics
NPI:1366659492
Name:GREEN, MICHELLE L (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18-B LENOX POINTE, N.E.
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3168
Mailing Address - Country:US
Mailing Address - Phone:404-840-4403
Mailing Address - Fax:404-840-9296
Practice Address - Street 1:18-B LENOX POINTE, N.E.
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-3168
Practice Address - Country:US
Practice Address - Phone:404-840-4403
Practice Address - Fax:404-840-9296
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002895103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist