Provider Demographics
NPI:1386212082
Name:GREEN, REBEKAH MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:REBEKAH
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MS
Other - First Name:REBEKAH
Other - Middle Name:MARIE
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:5675 VERTA DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-9493
Mailing Address - Country:US
Mailing Address - Phone:616-382-0533
Mailing Address - Fax:
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-382-0533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist