Healthcare Provider Details

I. General information

NPI: 1013246131
Provider Name (Legal Business Name): WILLIAM MACK GREEN LCSW, LSAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2009
Last Update Date: 12/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N MAIN ST
BOUNTIFUL UT
84010-6162
US

IV. Provider business mailing address

590 E CENTER ST
CENTERVILLE UT
84014-2305
US

V. Phone/Fax

Practice location:
  • Phone: 801-244-5166
  • Fax:
Mailing address:
  • Phone: 801-244-5166
  • Fax: 801-295-2618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4932942-6006
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4932942-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: