Provider Demographics
NPI:1083456131
Name:GREEN, LATOYA LASHEEKIE
Entity type:Individual
Prefix:
First Name:LATOYA
Middle Name:LASHEEKIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20666 HOLLYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1161
Mailing Address - Country:US
Mailing Address - Phone:313-608-8883
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:313-833-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704386104163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent