Provider Demographics
NPI:1063744167
Name:GREEN, MICHAEL ANDREW
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANDREW
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 TRADERS POINTE CIR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-8546
Mailing Address - Country:US
Mailing Address - Phone:402-216-1789
Mailing Address - Fax:
Practice Address - Street 1:5115 F STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68117-2807
Practice Address - Country:US
Practice Address - Phone:402-397-9866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health