Healthcare Provider Details

I. General information

NPI: 1609364363
Provider Name (Legal Business Name): MICHELLE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/08/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10201 MISSION GORGE RD STE O
SANTEE CA
92071-3040
US

IV. Provider business mailing address

10201 MISSION GORGE RD STE O
SANTEE CA
92071-3040
US

V. Phone/Fax

Practice location:
  • Phone: 619-383-6862
  • Fax: 619-312-2661
Mailing address:
  • Phone: 619-383-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: