MEDICARE: DIANA GREEN MSW, LCSW

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	1041C0700X	Clinical Social Worker	C012203	NC

General Provider Information

NPI Number	:	1710566351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA GREEN MSW, LCSW

Provider Business Mailing Address
First Line	:	2733 LYNDHURST AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-4107
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2733 LYNDHURST AVE
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-4107
Country	:	US
Telephone Number	:	336-682-1266
Fax Number	:

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

Provider Enumeration Date	:	04/02/2021
Last Update Date	:	04/02/2021

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