1174927024 NPI number — GREEN ROOTS COUNSELING

Table of content: (NPI 1174927024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174927024 NPI number — GREEN ROOTS COUNSELING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREEN ROOTS COUNSELING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1174927024
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1537 MORGAN RD NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREMERTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98312-2626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-471-2953
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
423 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98337-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-471-2953
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HENSLEY
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MENTAL HEALTH COUNSELOR
Authorized Official Telephone Number:
360-471-2953

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MC 60323887 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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