Provider Demographics
NPI:1205123601
Name:GREEN, MICHELLE ELLEN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELLEN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 W CLINTON AVE BLDG B #134
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93705-4206
Mailing Address - Country:US
Mailing Address - Phone:559-293-5441
Mailing Address - Fax:
Practice Address - Street 1:2550 W CLINTON AVE BLDG B #134
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-4206
Practice Address - Country:US
Practice Address - Phone:559-293-5441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-EPOTRN175T00000X
175T00000X, 101YA0400X, 103K00000X, 172V00000X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172V00000XOther Service ProvidersCommunity Health Worker