Provider Demographics
NPI:1275245755
Name:GREEN, HEATHER MICHELLE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MICHELLE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-8149
Mailing Address - Country:US
Mailing Address - Phone:706-244-6779
Mailing Address - Fax:
Practice Address - Street 1:504 SHADY LN
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577-8149
Practice Address - Country:US
Practice Address - Phone:706-244-6779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health