Healthcare Provider Details

I. General information

NPI: 1003071879
Provider Name (Legal Business Name): MIRIAM E GREEN M.S.W., L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 E CHERRY ST
SPRINGFIELD MO
65802-3429
US

IV. Provider business mailing address

1330 E CHERRY ST
SPRINGFIELD MO
65802-3429
US

V. Phone/Fax

Practice location:
  • Phone: 417-862-1377
  • Fax:
Mailing address:
  • Phone: 417-862-1377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2005025788
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: