Provider Demographics
NPI:1629156658
Name:GREEN, BETTY MILLER (MDIV, MED, MA,)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:MILLER
Last Name:GREEN
Suffix:
Gender:F
Credentials:MDIV, MED, MA,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8749 LILLY DRIVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-9651
Mailing Address - Country:US
Mailing Address - Phone:313-961-7990
Mailing Address - Fax:
Practice Address - Street 1:220 BAGLEY
Practice Address - Street 2:SUITE 1100
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226
Practice Address - Country:US
Practice Address - Phone:313-961-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012675103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist