Provider Demographics
NPI:1568424166
Name:WILLETTE-GREEN, VIRGINIA M (OTR CHT)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:M
Last Name:WILLETTE-GREEN
Suffix:
Gender:F
Credentials:OTR CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W FRONT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2236
Mailing Address - Country:US
Mailing Address - Phone:231-995-9748
Mailing Address - Fax:231-995-9745
Practice Address - Street 1:701 W FRONT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2236
Practice Address - Country:US
Practice Address - Phone:231-995-9748
Practice Address - Fax:231-995-9745
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201002172225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
N13430005Medicare PIN
5654790001Medicare NSC