Provider Demographics
NPI:1821409152
Name:GREEN, MELYNDA SHAVONNE (LMSW)
Entity type:Individual
Prefix:MS
First Name:MELYNDA
Middle Name:SHAVONNE
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 1:16862 HUNTINGTON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-4053
Mailing Address - Country:US
Mailing Address - Phone:313-461-8601
Mailing Address - Fax:
Practice Address - Street 1:2715 S, BEATRICE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48217
Practice Address - Country:US
Practice Address - Phone:313-461-8601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-08
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087327104100000X
MI6801096718104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker