Healthcare Provider Details

I. General information

NPI: 1144836404
Provider Name (Legal Business Name): WALTER J. GREEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 MOSSY KNOLL DR
CORDOVA TN
38018-6671
US

IV. Provider business mailing address

1120 MOSSY KNOLL DR
CORDOVA TN
38018-6671
US

V. Phone/Fax

Practice location:
  • Phone: 901-334-6363
  • Fax:
Mailing address:
  • Phone: 901-334-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

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: