Provider Demographics
NPI:1205000502
Name:GREEN, MINNIE
Entity Type:Individual
Prefix:MS
First Name:MINNIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4446 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1136
Mailing Address - Country:US
Mailing Address - Phone:917-715-8165
Mailing Address - Fax:
Practice Address - Street 1:4446 HILL AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1136
Practice Address - Country:US
Practice Address - Phone:917-715-8165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities