Healthcare Provider Details

I. General information

NPI: 1912791427
Provider Name (Legal Business Name): ELIJAH JOSHUA GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N GORE AVE
WEBSTER GROVES MO
63119-1600
US

IV. Provider business mailing address

1182 GLENMEADE DR APT D
MARYLAND HEIGHTS MO
63043-4417
US

V. Phone/Fax

Practice location:
  • Phone: 844-424-3577
  • Fax:
Mailing address:
  • Phone: 314-922-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2025007543
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: