Provider Demographics
NPI:1003964354
Name:GREEN, DAVID M (MA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 HUBBARD ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1289
Mailing Address - Country:US
Mailing Address - Phone:269-673-1929
Mailing Address - Fax:269-686-0373
Practice Address - Street 1:327 HUBBARD ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1289
Practice Address - Country:US
Practice Address - Phone:269-673-1929
Practice Address - Fax:269-686-0373
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010595071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical