Healthcare Provider Details

I. General information

NPI: 1790821866
Provider Name (Legal Business Name): GREEN DOOR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 TAYLOR ST NW
WASHINGTON DC
20011-5617
US

IV. Provider business mailing address

1221 TAYLOR ST NW
WASHINGTON DC
20011-5617
US

V. Phone/Fax

Practice location:
  • Phone: 202-464-9200
  • Fax: 202-464-5730
Mailing address:
  • Phone: 202-464-9200
  • Fax: 202-464-5730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADD13912
License Number StateDC

VIII. Authorized Official

Name: MR. MICHAEL CLANCY
Title or Position: DEPUTY DIRECTOR
Credential:
Phone: 202-464-9200