Healthcare Provider Details

I. General information

NPI: 1740196567
Provider Name (Legal Business Name): MIKAIL S GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 SHAWNEE RD STE 101
ALEXANDRIA VA
22312-2377
US

IV. Provider business mailing address

12516 WOODSTOCK DR E
UPPER MARLBORO MD
20772-5131
US

V. Phone/Fax

Practice location:
  • Phone: 888-344-5977
  • Fax:
Mailing address:
  • Phone: 202-510-0133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-399394
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: