Provider Demographics
NPI:1497537047
Name:GREEN, DESIREE
Entity Type:Individual
Prefix:
First Name:DESIREE
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:257 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-8033
Practice Address - Country:US
Practice Address - Phone:609-792-0013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician