MEDICARE: WANDA 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	251C00000X	Developmentally Disabled Services Day Training Agency	3781	VA

General Provider Information

NPI Number	:	1760197859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA GREEN

Provider Business Mailing Address
First Line	:	3316 CLIFF AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2753
Country	:	US
Telephone Number	:	804-397-4504
Fax Number	:

Provider Business Practice Location Address
First Line	:	3316 CLIFF AVE
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23222-2753
Country	:	US
Telephone Number	:	804-397-4504
Fax Number	:

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

Provider Enumeration Date	:	01/23/2023
Last Update Date	:	01/23/2023

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Directions to “ WANDA GREEN ” Practice Location

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