Healthcare Provider Details

I. General information

NPI: 1386047215
Provider Name (Legal Business Name): MELISSA M GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA M MOROZ

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9192 WARSAW RD
LE ROY NY
14482-8943
US

IV. Provider business mailing address

15 MAPLE AVE
LE ROY NY
14482-1021
US

V. Phone/Fax

Practice location:
  • Phone: 585-507-9779
  • Fax:
Mailing address:
  • Phone: 585-507-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number73082442
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73082442
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: