Basic Information
| Provider Information | |||||||||
| NPI: | 1861801185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | JESSICA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.S., M.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN STREET | ||||||||
| Address2: | SUITE 818 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084509127 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 340 MAIN STREET | ||||||||
| Address2: | SUITE 818 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087914976 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2014 | ||||||||
| LastUpdateDate: | 08/12/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.