Provider Demographics
NPI:1811698939
Name:GREEN, LISSA DEE (RD, LDN,CDCES)
Entity type:Individual
Prefix:
First Name:LISSA
Middle Name:DEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD, LDN,CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 230
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-7990
Practice Address - Fax:803-434-4669
Is Sole Proprietor?:No
Enumeration Date:2023-03-15
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI715365133V00000X
SC182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered