Healthcare Provider Details

I. General information

NPI: 1255735247
Provider Name (Legal Business Name): SAMUEL ELLIS GREEN M.A., L.M.H.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9027 SUTPHIN BLVD
JAMAICA NY
11435-3647
US

IV. Provider business mailing address

9027 SUTPHIN BLVD
JAMAICA NY
11435-3647
US

V. Phone/Fax

Practice location:
  • Phone: 718-526-8400
  • Fax: 718-297-8658
Mailing address:
  • Phone: 718-526-8400
  • Fax: 718-297-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number003591
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: