MEDICARE: PENNY YVETTE GREEN LGSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	G11093	MD

General Provider Information

NPI Number	:	1114095379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PENNY YVETTE GREEN LGSW

Provider Business Mailing Address
First Line	:	2204 MARYLAND AVENUE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218
Country	:	US
Telephone Number	:	410-467-6040
Fax Number	:	410-235-8807

Provider Business Practice Location Address
First Line	:	5225 YORK RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212
Country	:	US
Telephone Number	:	410-467-6040
Fax Number	:	410-235-8807

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	07/08/2007

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