Healthcare Provider Details

I. General information

NPI: 1467508630
Provider Name (Legal Business Name): JOANNE GREEN, PHD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 CENTURY BLVD NE SUITE B
ATLANTA GA
30345-3310
US

IV. Provider business mailing address

1760 CENTURY BLVD NE SUITE B
ATLANTA GA
30345-3310
US

V. Phone/Fax

Practice location:
  • Phone: 404-909-9455
  • Fax:
Mailing address:
  • Phone: 404-909-9455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY001316
License Number StateGA

VIII. Authorized Official

Name: JOANNE GREEN
Title or Position: PRINCIPAL
Credential:
Phone: 404-909-9455