MEDICARE: ANDREA R. GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801090684	MI

General Provider Information

NPI Number	:	1114213840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA R. GREEN

Provider Business Mailing Address
First Line	:	250 E HARBORTOWN DR
Second Line	:	UNIT 906
City	:	DETROIT
State	:	MI
Zip	:	48207-5027
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	37899 W 12 MILE RD
Second Line	:	SUITE 130
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-3048
Country	:	US
Telephone Number	:	248-476-2229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2011
Last Update Date	:	06/21/2011

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