Provider Demographics
NPI:1265631493
Name:GREEN, HEATH A (LBSW, MA)
Entity Type:Individual
Prefix:
First Name:HEATH
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:LBSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-0001
Mailing Address - Country:US
Mailing Address - Phone:231-935-6380
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9558
Practice Address - Country:US
Practice Address - Phone:877-398-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802074656104100000X
MI6401009334101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6401009334OtherSTATE OF MICHIGAN