Healthcare Provider Details

I. General information

NPI: 1700812765
Provider Name (Legal Business Name): HARRIETTE DENICE GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 W HENDERSON AVE
PORTERVILLE CA
93257-1490
US

IV. Provider business mailing address

8267 GREENVIEW DR
JONESBORO GA
30236-4183
US

V. Phone/Fax

Practice location:
  • Phone: 559-788-1250
  • Fax: 559-782-4712
Mailing address:
  • Phone: 770-825-2134
  • Fax: 862-298-0744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC144317
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number051654
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number4301050673
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301050673
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number4301050673
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number4301050673
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: