Healthcare Provider Details

I. General information

NPI: 1154231231
Provider Name (Legal Business Name): SANDRA PATRICIA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 VILLAGE CENTRE DR
LOGANVILLE GA
30052-8768
US

IV. Provider business mailing address

2350 VILLAGE CENTRE DR
LOGANVILLE GA
30052-8768
US

V. Phone/Fax

Practice location:
  • Phone: 973-207-8047
  • Fax:
Mailing address:
  • Phone: 973-207-8047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberAPRN-NP271441
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: