Provider Demographics
NPI:1811005234
Name:GREEN, ROBERT HART (MA, LLP)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:HART
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:913 GREENHILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-2721
Mailing Address - Country:US
Mailing Address - Phone:734-668-2992
Mailing Address - Fax:734-668-2992
Practice Address - Street 1:3830 PACKARD ST
Practice Address - Street 2:SUITE #250
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2051
Practice Address - Country:US
Practice Address - Phone:734-395-2028
Practice Address - Fax:734-668-2992
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005069103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISP0896043OtherBLUECROSSBLUESHIELDOFMICH