Healthcare Provider Details

I. General information

NPI: 1235033101
Provider Name (Legal Business Name): CARLY MARGARET GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8230 LEESBURG PIKE STE 740
VIENNA VA
22182-2641
US

IV. Provider business mailing address

4512 UNIVERSITY DR APT 1504
FAIRFAX VA
22030-4634
US

V. Phone/Fax

Practice location:
  • Phone: 877-504-4141
  • Fax:
Mailing address:
  • Phone: 877-504-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: