Provider Demographics
NPI:1205578630
Name:GREEN, PAULA BRETZ (RN)
Entity type:Individual
Prefix:
First Name:PAULA
Middle Name:BRETZ
Last Name:GREEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 HERITAGE WAY NE STE 302
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-4544
Mailing Address - Country:US
Mailing Address - Phone:703-771-5100
Mailing Address - Fax:703-777-0170
Practice Address - Street 1:102 HERITAGE WAY NE STE 302
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-4544
Practice Address - Country:US
Practice Address - Phone:703-771-5100
Practice Address - Fax:703-777-0170
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001099276261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)