MEDICARE: DR. LINDA T GREEN PSYD

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	103TC0700X	Clinical Psychologist	6301005056	MI
2	103TS0200X	School Psychologist		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7215028	OTHER	MI	AETNA
2	11277424	OTHER	MI	CAQH
3	298871000	OTHER	MI	MAGELLAN
4	620F348200	OTHER	MI	BCBS
5	119609	OTHER	MI	VALUE OPTIONS

General Provider Information

NPI Number	:	1881683050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LINDA T GREEN PSYD

Provider Business Mailing Address
First Line	:	1591 FURNWALL ST
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-3824
Country	:	US
Telephone Number	:	248-258-8899
Fax Number	:	248-287-4633

Provider Business Practice Location Address
First Line	:	1591 FURNWALL ST
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-3824
Country	:	US
Telephone Number	:	248-258-8899
Fax Number	:	248-287-4633

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

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	02/15/2022

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