Provider Demographics
NPI:1497500425
Name:GREEN, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:230 TIDWELL ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENS
Mailing Address - State:AR
Mailing Address - Zip Code:71764-8354
Mailing Address - Country:US
Mailing Address - Phone:870-818-7190
Mailing Address - Fax:
Practice Address - Street 1:3286 W HILLSBORO ST STE A
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6734
Practice Address - Country:US
Practice Address - Phone:870-818-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services