1295932143 NPI number — MR. J. ALEX GREEN LCPC,LCADC,NCC,NBCCH

Table of content: MR. J. ALEX GREEN LCPC,LCADC,NCC,NBCCH (NPI 1295932143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295932143 NPI number — MR. J. ALEX GREEN LCPC,LCADC,NCC,NBCCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
J. ALEX
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCPC,LCADC,NCC,NBCCH
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:
1295932143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 MERIDENE DR
Provider Second Line Business Mailing Address:
SUITE 611
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21239-2032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-808-2786
Provider Business Mailing Address Fax Number:
410-715-6984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2115 N CHARLES ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21218-5760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-808-2786
Provider Business Practice Location Address Fax Number:
410-715-6984
Provider Enumeration Date:
07/02/2007

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 , with the licence number:  LC2308 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: LC2308 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 014003101 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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