Provider Demographics
NPI:1841034295
Name:GREEN, LARESA
Entity type:Individual
Prefix:
First Name:LARESA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4317 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ECORSE
Mailing Address - State:MI
Mailing Address - Zip Code:48229-1162
Mailing Address - Country:US
Mailing Address - Phone:313-520-5311
Mailing Address - Fax:
Practice Address - Street 1:4317 11TH ST
Practice Address - Street 2:
Practice Address - City:ECORSE
Practice Address - State:MI
Practice Address - Zip Code:48229-1162
Practice Address - Country:US
Practice Address - Phone:313-520-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service