Healthcare Provider Details

I. General information

NPI: 1437040649
Provider Name (Legal Business Name): COBLAH Q GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/29/2025
Certification Date: 07/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 VICKERS RD
BALTIMORE MD
21216-1940
US

IV. Provider business mailing address

3210 VICKERS RD
BALTIMORE MD
21216-1940
US

V. Phone/Fax

Practice location:
  • Phone: 443-413-0468
  • Fax:
Mailing address:
  • Phone: 443-924-3754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: