MEDICARE: DR. LESLIE WEISS GREEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	6301005638	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	620F33143	OTHER	MI	BLUE CROSS PIN

General Provider Information

NPI Number	:	1073646774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESLIE WEISS GREEN PH.D.

Provider Business Mailing Address
First Line	:	PO BOX 1563
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48099-1563
Country	:	US
Telephone Number	:	248-593-0678
Fax Number	:	248-593-9766

Provider Business Practice Location Address
First Line	:	755 W BIG BEAVER RD
Second Line	:	SUITE 414
City	:	TROY
State	:	MI
Zip	:	48084-4900
Country	:	US
Telephone Number	:	248-593-0678
Fax Number	:	248-593-9766

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	07/08/2007

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