Healthcare Provider Details

I. General information

NPI: 1194172197
Provider Name (Legal Business Name): ALLISIA N GREEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 RETREAT AVENUE HARTFORD HOSPITAL PSYCHIATRY DEPT
HARTFORD CT
06106-3309
US

IV. Provider business mailing address

200 RETREAT AVENUE HARTFORD HOSPITAL PSYCHIATRY DEPT
HARTFORD CT
06106-3309
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-0020
  • Fax:
Mailing address:
  • Phone: 860-696-0020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003476
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: