Healthcare Provider Details

I. General information

NPI: 1366716631
Provider Name (Legal Business Name): ELLE M GREEN LISW-CP LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date: 07/26/2025
Reactivation Date: 09/25/2026

III. Provider practice location address

8640 RIDGELYS CHOICE DR
BALTIMORE MD
21236-3029
US

IV. Provider business mailing address

1985 RIVIERA DR STE 103
MT PLEASANT SC
29464-7582
US

V. Phone/Fax

Practice location:
  • Phone: 410-268-8191
  • Fax:
Mailing address:
  • Phone: 443-527-3418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17398
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number.16264
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: