Healthcare Provider Details

I. General information

NPI: 1205123601
Provider Name (Legal Business Name): MICHELLE ELLEN GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 W CLINTON AVE BLDG B #134
FRESNO CA
93705-4206
US

IV. Provider business mailing address

2550 W CLINTON AVE BLDG B #134
FRESNO CA
93705-4206
US

V. Phone/Fax

Practice location:
  • Phone: 559-293-5441
  • Fax:
Mailing address:
  • Phone: 559-293-5441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-EPOTRN
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: