Healthcare Provider Details

I. General information

NPI: 1457930976
Provider Name (Legal Business Name): RENEE MICHELE GREEN PSY.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N 4TH AVE
HOPEWELL VA
23860-2503
US

IV. Provider business mailing address

269 MEDICAL PARK BLVD
PETERSBURG VA
23805-9337
US

V. Phone/Fax

Practice location:
  • Phone: 804-541-0918
  • Fax: 804-863-4626
Mailing address:
  • Phone: 804-861-0700
  • Fax: 804-863-4626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007347
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810007347
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: