Provider Demographics
NPI:1558693903
Name:GREEN, ROARY XAVIER (LMSW)
Entity Type:Individual
Prefix:MR
First Name:ROARY
Middle Name:XAVIER
Last Name:GREEN
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11202 BRYDAN ST APT 6
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3955
Mailing Address - Country:US
Mailing Address - Phone:313-622-5521
Mailing Address - Fax:
Practice Address - Street 1:11202 BRYDAN ST
Practice Address - Street 2:APT 6
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-6240
Practice Address - Country:US
Practice Address - Phone:313-622-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-10
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801080908104100000X, 1041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool