MEDICARE: SHERRY GREEN MSW, LBS

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	101YM0800X	Mental Health Counselor	BH000155	PA
2	103K00000X	Behavior Analyst	BH000155	PA
3	104100000X	Social Worker	BH000155	PA
4	1041C0700X	Clinical Social Worker	BH000155	PA
5	1041S0200X	School Social Worker	BH000155	PA

General Provider Information

NPI Number	:	1285017251
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERRY GREEN MSW, LBS

Provider Business Mailing Address
First Line	:	PO BOX 828
Second Line	:
City	:	GLENSIDE
State	:	PA
Zip	:	19038-0828
Country	:	US
Telephone Number	:	215-528-2927
Fax Number	:

Provider Business Practice Location Address
First Line	:	708 E SHARPNACK ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19119-1535
Country	:	US
Telephone Number	:	215-528-2927
Fax Number	:

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

Provider Enumeration Date	:	07/08/2015
Last Update Date	:	07/08/2015

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