=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063010676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELINDA ANNETTE GREEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2020
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 MEADOWBROOK AVE
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-774-4670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 MEADOWBROOK AVE
-----------------------------------------------------
City | BOARDMAN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44512-2605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-774-4670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------