Healthcare Provider Details

I. General information

NPI: 1073919478
Provider Name (Legal Business Name): HUMPUNCHEEN GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3669 SW 2ND AVE
GAINESVILLE FL
32607-2856
US

IV. Provider business mailing address

11808 N OHIO ST
DUNNELLON FL
34431-6724
US

V. Phone/Fax

Practice location:
  • Phone: 352-554-6164
  • Fax: 352-240-6876
Mailing address:
  • Phone: 352-462-7021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-15-03102
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: