=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093087710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIA GREEN C.C.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2012
-----------------------------------------------------
Last Update Date | 01/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5606 SHIELDS DR
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20817-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-493-0023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4301 VERPLANCK PL NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20016-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-246-2467
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 06343
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------