Healthcare Provider Details

I. General information

NPI: 1457853236
Provider Name (Legal Business Name): SHERRILLE GREENE L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 AUTUMN LEAF CIRCLE
MCDONOUGH GA
30253
US

IV. Provider business mailing address

6645 PEACHTREE DUNWOODY RD
ATLANTA GA
30328-1606
US

V. Phone/Fax

Practice location:
  • Phone: 804-300-9642
  • Fax:
Mailing address:
  • Phone: 770-455-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW009041
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: