Provider Demographics
NPI:1386047215
Name:GREEN, MELISSA M
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:MOROZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-1021
Mailing Address - Country:US
Mailing Address - Phone:585-507-9779
Mailing Address - Fax:
Practice Address - Street 1:9192 WARSAW RD
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:NY
Practice Address - Zip Code:14482-8943
Practice Address - Country:US
Practice Address - Phone:585-507-9779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY730824421041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01368845Medicaid