Provider Demographics
NPI:1457930976
Name:GREEN, RENEE MICHELE (PSYD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:MICHELE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9337
Mailing Address - Country:US
Mailing Address - Phone:804-861-0700
Mailing Address - Fax:804-863-4626
Practice Address - Street 1:207 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-2503
Practice Address - Country:US
Practice Address - Phone:804-541-0918
Practice Address - Fax:804-863-4626
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-02
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0810007347103TC0700X
VA0810007347103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical