Healthcare Provider Details

I. General information

NPI: 1073628863
Provider Name (Legal Business Name): ELAINE REEVES GREEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14150 PARKEAST CIR STE 200
CHANTILLY VA
20151-2295
US

IV. Provider business mailing address

3224 S UTAH ST
ARLINGTON VA
22206-1908
US

V. Phone/Fax

Practice location:
  • Phone: 703-968-4000
  • Fax:
Mailing address:
  • Phone: 703-820-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0101030027
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: