Healthcare Provider Details

I. General information

NPI: 1003539503
Provider Name (Legal Business Name): DOUGLAS JAMES GREEN II MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 WINDSOR ST
HARTFORD CT
06120-2418
US

IV. Provider business mailing address

555 WINDSOR ST
HARTFORD CT
06120-2418
US

V. Phone/Fax

Practice location:
  • Phone: 860-560-5600
  • Fax:
Mailing address:
  • Phone: 860-560-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number071
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: