Provider Demographics
NPI:1700812765
Name:GREEN, HARRIETTE DENICE (MD)
Entity Type:Individual
Prefix:
First Name:HARRIETTE
Middle Name:DENICE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8267 GREENVIEW DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-4183
Mailing Address - Country:US
Mailing Address - Phone:770-825-2134
Mailing Address - Fax:862-298-0744
Practice Address - Street 1:1055 W HENDERSON AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-1490
Practice Address - Country:US
Practice Address - Phone:559-788-1250
Practice Address - Fax:559-782-4712
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1443172084P0804X
GA0516542084P0800X
MI43010506732084F0202X, 2084P0800X, 2084P0802X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4732421Medicaid
MI4732412Medicaid
MI4732430Medicaid
MI4732440Medicaid
MI4732440Medicaid