Healthcare Provider Details

I. General information

NPI: 1538358668
Provider Name (Legal Business Name): VICKIE M. GREEN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27450 SCHOENHERR RD SUITE 100A
WARREN MI
48088-6683
US

IV. Provider business mailing address

27450 SCHOENHERR RD SUITE 100A
WARREN MI
48088-6683
US

V. Phone/Fax

Practice location:
  • Phone: 586-582-7825
  • Fax:
Mailing address:
  • Phone: 586-582-7825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License Number5201001712
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: