Provider Demographics
NPI:1811687247
Name:GREEN, MICHAEL GEORGE (LADC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GEORGE
Last Name:GREEN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 GRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06615-5500
Mailing Address - Country:US
Mailing Address - Phone:203-556-4632
Mailing Address - Fax:
Practice Address - Street 1:350 GRAHAM ST
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06615-5500
Practice Address - Country:US
Practice Address - Phone:203-556-4632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1498101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)