Provider Demographics
NPI:1003682311
Name:GREEN, MICAH TONARD (RBT)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:TONARD
Last Name:GREEN
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 SW 38TH DR # 112B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-2830
Mailing Address - Country:US
Mailing Address - Phone:904-208-3314
Mailing Address - Fax:
Practice Address - Street 1:4907 NW 43RD ST STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-2007
Practice Address - Country:US
Practice Address - Phone:352-372-0047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
FL23-311222106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician