Provider Demographics
NPI:1700356045
Name:GREEN, MARCUS DUWAN
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:DUWAN
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3590 RUE FORET APT 101
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-2843
Mailing Address - Country:US
Mailing Address - Phone:810-394-6266
Mailing Address - Fax:
Practice Address - Street 1:2221 LIVERNOIS RD STE 101
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1603
Practice Address - Country:US
Practice Address - Phone:810-766-9772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician