Healthcare Provider Details

I. General information

NPI: 1851868616
Provider Name (Legal Business Name): BENITA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 MEMORIAL DR STE 121
STONE MOUNTAIN GA
30083-3154
US

IV. Provider business mailing address

256 STRICKLAND ST
FAIRBURN GA
30213-1130
US

V. Phone/Fax

Practice location:
  • Phone: 404-254-4500
  • Fax:
Mailing address:
  • Phone: 404-895-9071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC015186
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number005547
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: