Provider Demographics
NPI:1275927279
Name:LANDRIA GREEN, PLLC
Entity Type:Organization
Organization Name:LANDRIA GREEN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANDRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEALS GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-919-8627
Mailing Address - Street 1:42861 STRATFORD DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-1729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42861 STRATFORD DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-1729
Practice Address - Country:US
Practice Address - Phone:248-919-8627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
MI71010000784235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty