MEDICARE: KRISTA MARIE GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	112137	NY

General Provider Information

NPI Number	:	1003496878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTA MARIE GREEN

Provider Business Mailing Address
First Line	:	3095 29TH ST APT 3F
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11102-2729
Country	:	US
Telephone Number	:	315-867-7474
Fax Number	:

Provider Business Practice Location Address
First Line	:	3095 29TH ST APT 3F
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11102-2729
Country	:	US
Telephone Number	:	315-867-7474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2021
Last Update Date	:	04/14/2021

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Directions to “ KRISTA MARIE GREEN ” Practice Location

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