Healthcare Provider Details

I. General information

NPI: 1205448354
Provider Name (Legal Business Name): KRISELLE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41800 W 11 MILE RD STE 110
NOVI MI
48375-1818
US

IV. Provider business mailing address

41800 W 11 MILE RD STE 110
NOVI MI
48375-1818
US

V. Phone/Fax

Practice location:
  • Phone: 877-693-5543
  • Fax: 248-221-1775
Mailing address:
  • Phone: 877-693-5543
  • Fax: 248-221-1775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: