Healthcare Provider Details

I. General information

NPI: 1396860821
Provider Name (Legal Business Name): JUDITH H GREEN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/04/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 ACACIA CIRCLE #504
INDIAN HEAD PARK IL
60525
US

IV. Provider business mailing address

125 ACACIA CIRCLE #504
INDIAN HEAD PARK IL
60525
US

V. Phone/Fax

Practice location:
  • Phone: 630-841-5573
  • Fax:
Mailing address:
  • Phone: 630-841-5573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCERT# 5603
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180002622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: