Individual
LATESHA GREEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
3409 DOMINION GREEN DR, CHARLOTTE, NC 28269-7932
(704) 906-4522
Mailing address
3409 DOMINION GREEN DR, CHARLOTTE, NC 28269-7932
(704) 906-4522
Taxonomy
Speciality
Code
Description
License number
State
261QD1600X
Developmental Disabilities Clinic/Center
—
NC
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
NC
Other
Enumeration date
07/29/2022
Last updated
07/29/2022
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