Provider Demographics
NPI:1992269039
Name:GREEN, MICHAEL (CADC, MISA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:CADC, MISA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 DIXIE HWY STE D
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1485
Mailing Address - Country:US
Mailing Address - Phone:708-335-1155
Mailing Address - Fax:
Practice Address - Street 1:17100 DIXIE HWY STE D
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1485
Practice Address - Country:US
Practice Address - Phone:708-335-1155
Practice Address - Fax:708-335-1155
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)