Healthcare Provider Details

I. General information

NPI: 1992026249
Provider Name (Legal Business Name): DIANE J GREEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1657 MERRIMAC TRL
WILLIAMSBURG VA
23185-5624
US

IV. Provider business mailing address

201 BRITTANIA DR
WILLIAMSBURG VA
23185-5789
US

V. Phone/Fax

Practice location:
  • Phone: 757-220-3200
  • Fax: 757-253-4371
Mailing address:
  • Phone: 757-220-3200
  • Fax: 757-253-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0701004798
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: