Provider Demographics
NPI:1629527213
Name:GREEN, BRIDGETTE VANNESSA (MS, LIFE COACH)
Entity Type:Individual
Prefix:MS
First Name:BRIDGETTE
Middle Name:VANNESSA
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, LIFE COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 NW 187TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-2717
Mailing Address - Country:US
Mailing Address - Phone:786-592-8812
Mailing Address - Fax:
Practice Address - Street 1:2020 NW 187TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-2717
Practice Address - Country:US
Practice Address - Phone:786-592-8812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-24
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL812785084Medicaid
FL812785084Medicaid
FL812785084Medicare UPIN