Healthcare Provider Details

I. General information

NPI: 1053980961
Provider Name (Legal Business Name): MRS. CHRISTINE JEWEL GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 CYMAN DR
CHICOPEE MA
01013-3023
US

IV. Provider business mailing address

77 CYMAN DR
CHICOPEE MA
01013-3023
US

V. Phone/Fax

Practice location:
  • Phone: 413-374-7478
  • Fax:
Mailing address:
  • Phone: 413-374-7478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLN96634
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: