1376822445 NPI number — MR. DOUGLAS GREEN MA, LPC

Table of content: MR. DOUGLAS GREEN MA, LPC (NPI 1376822445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376822445 NPI number — MR. DOUGLAS GREEN MA, LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
DOUGLAS
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MA, LPC
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:
1376822445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
153 REDMON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRONT ROYAL
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22630-4957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
571-208-2056
Provider Business Mailing Address Fax Number:
703-649-6471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8715 PLANTATION LN
Provider Second Line Business Practice Location Address:
STE 301 A
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-8323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
571-232-6506
Provider Business Practice Location Address Fax Number:
703-649-6471
Provider Enumeration Date:
08/08/2011

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: 101Y00000X , with the licence number:  0701005090 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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