Provider Demographics
NPI:1104181809
Name:GREEN, MISTI MARIE (LMHC, LMFT, CRC)
Entity Type:Individual
Prefix:
First Name:MISTI
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMHC, LMFT, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9478
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34206-9478
Mailing Address - Country:US
Mailing Address - Phone:941-782-4299
Mailing Address - Fax:941-782-4301
Practice Address - Street 1:379 6TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8820
Practice Address - Country:US
Practice Address - Phone:941-782-4100
Practice Address - Fax:941-782-4101
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12629101YM0800X
FLMT2905106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health