Provider Demographics
NPI:1093087710
Name:GREEN, MIA (CCC)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 VERPLANCK PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-2427
Mailing Address - Country:US
Mailing Address - Phone:202-246-2467
Mailing Address - Fax:
Practice Address - Street 1:5606 SHIELDS DR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-3571
Practice Address - Country:US
Practice Address - Phone:301-493-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06343235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist