Healthcare Provider Details

I. General information

NPI: 1558693903
Provider Name (Legal Business Name): ROARY XAVIER GREEN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2010
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11202 BRYDAN ST APT 6
TAYLOR MI
48180-6240
US

IV. Provider business mailing address

11202 BRYDAN ST APT 6
TAYLOR MI
48180-3955
US

V. Phone/Fax

Practice location:
  • Phone: 313-622-5521
  • Fax:
Mailing address:
  • Phone: 313-622-5521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801080908
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080908
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801080908
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: