Healthcare Provider Details

I. General information

NPI: 1114697679
Provider Name (Legal Business Name): DWAYNE GREEN PS-A
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MARKET AVE N STE 1500B
CANTON OH
44702-2303
US

IV. Provider business mailing address

800 MARKET AVE N STE 1500B
CANTON OH
44702-2303
US

V. Phone/Fax

Practice location:
  • Phone: 234-214-0469
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: