Provider Demographics
NPI:1487177606
Name:GREEN, CAILEY MICHELE
Entity type:Individual
Prefix:
First Name:CAILEY
Middle Name:MICHELE
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 1:5243 W 6600 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-4413
Mailing Address - Country:US
Mailing Address - Phone:801-635-9904
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-8835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10107124-35021041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool