Healthcare Provider Details

I. General information

NPI: 1184546368
Provider Name (Legal Business Name): LARRY GREEN JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 PARK TOWER DR STE 200
VIENNA VA
22180-7394
US

IV. Provider business mailing address

4400 SIMPSON MILL WAY
WOODBRIDGE VA
22192-5584
US

V. Phone/Fax

Practice location:
  • Phone: 571-282-0092
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: