Provider Demographics
NPI:1982827697
Name:GREEN, MICHAEL BRIAN (MOTR/L)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:BRIAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:FRANKFORD
Mailing Address - State:WV
Mailing Address - Zip Code:24938-0196
Mailing Address - Country:US
Mailing Address - Phone:304-799-7375
Mailing Address - Fax:
Practice Address - Street 1:HC 37 BOX 213C
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9536
Practice Address - Country:US
Practice Address - Phone:304-645-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1385225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV04112007434566Medicaid