Healthcare Provider Details

I. General information

NPI: 1427359132
Provider Name (Legal Business Name): DWAYNE T GREEN LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 02/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 SHAWAN RD STE 101C
HUNT VALLEY MD
21030-1373
US

IV. Provider business mailing address

5 SHAWAN RD STE 101C
HUNT VALLEY MD
21030-1373
US

V. Phone/Fax

Practice location:
  • Phone: 443-982-0692
  • Fax: 443-982-0616
Mailing address:
  • Phone: 443-982-0692
  • Fax: 443-982-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC3757
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC3757
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: