Provider Demographics
NPI:1902690241
Name:GREEN, MYISHA JOHNNE
Entity type:Individual
Prefix:
First Name:MYISHA
Middle Name:JOHNNE
Last Name:GREEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 WHITMORE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-2470
Mailing Address - Country:US
Mailing Address - Phone:810-775-3300
Mailing Address - Fax:
Practice Address - Street 1:5841 WHITMORE LAKE RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2470
Practice Address - Country:US
Practice Address - Phone:810-775-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician