Basic Information
| Provider Information | |||||||||
| NPI: | 1104181809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MISTI | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LMHC, LMFT, CRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9478 | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342069478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417824299 | ||||||||
| FaxNumber: | 9417824301 | ||||||||
| Practice Location | |||||||||
| Address1: | 379 6TH AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417824100 | ||||||||
| FaxNumber: | 9417824101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2012 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH12629 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MT2905 | FL | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.