Healthcare Provider Details

I. General information

NPI: 1376123778
Provider Name (Legal Business Name): GREENSPACE COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 08/23/2024
Certification Date: 08/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6950 W MOOSE RIDGE CIR
WASILLA AK
99623-9888
US

IV. Provider business mailing address

10630 LITTLE PATUXENT PKWY STE 314J
COLUMBIA MD
21044-6216
US

V. Phone/Fax

Practice location:
  • Phone: 443-766-2269
  • Fax: 907-416-4542
Mailing address:
  • Phone: 443-766-2269
  • Fax: 866-629-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1588606305
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: PARIS P TAYLOR
Title or Position: OWNER
Credential:
Phone: 443-355-7030