Healthcare Provider Details

I. General information

NPI: 1114895471
Provider Name (Legal Business Name): SYNNAMON ROSETTA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3348 PEACHTREE RD NE STE 700
ATLANTA GA
30326-1682
US

IV. Provider business mailing address

3348 PEACHTREE RD NE STE 700
ATLANTA GA
30326-1682
US

V. Phone/Fax

Practice location:
  • Phone: 470-500-0105
  • Fax: 646-859-4440
Mailing address:
  • Phone: 470-500-0105
  • Fax: 646-859-4440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: