1902921299 NPI number — MR. JAMES THEODORE GREEN SR. LCPC

Table of content: MR. JAMES THEODORE GREEN SR. LCPC (NPI 1902921299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902921299 NPI number — MR. JAMES THEODORE GREEN SR. LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
JAMES
Provider Middle Name:
THEODORE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
LCPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902921299
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7400 S RACINE AVE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60636-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-874-9715
Provider Business Mailing Address Fax Number:
773-874-9715

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7400 S RACINE AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60636-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-874-9715
Provider Business Practice Location Address Fax Number:
773-874-9715
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01636560 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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