Healthcare Provider Details

I. General information

NPI: 1457151706
Provider Name (Legal Business Name): DESTINEE SIMONE GREEN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

27408 STRAWBERRY LN APT 202
FARMINGTON HILLS MI
48334-5065
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax:
Mailing address:
  • Phone: 313-522-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502008400
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: