MEDICARE: MOLLY GREEN CCC-SLP

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	235Z00000X	Speech-Language Pathologist	7554	TN

General Provider Information

NPI Number	:	1578383642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY GREEN CCC-SLP

Provider Business Mailing Address
First Line	:	416 S 4TH ST
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-4711
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1084 E COUNTY HOME RD
Second Line	:
City	:	UNION CITY
State	:	TN
Zip	:	38261-8006
Country	:	US
Telephone Number	:	731-487-9635
Fax Number	:

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

Provider Enumeration Date	:	10/14/2024
Last Update Date	:	10/14/2024

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Directions to “ MOLLY GREEN CCC-SLP” Practice Location

Language	Start Address	Practice Location

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