Provider Demographics
NPI:1770975260
Name:GREEN, BETHANY (LMSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5103 W PIERSON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-1395
Mailing Address - Country:US
Mailing Address - Phone:810-391-2923
Mailing Address - Fax:
Practice Address - Street 1:5103 W PIERSON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-1395
Practice Address - Country:US
Practice Address - Phone:810-391-2923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-20
Last Update Date:2016-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010666741041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical