MEDICARE: MR. JAMES MATTHEW GREEN LPC

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	101YP2500X	Professional Counselor	862	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	37036	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1003890724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES MATTHEW GREEN LPC

Provider Business Mailing Address
First Line	:	1801 E 5TH ST
Second Line	:	SUITE 108-B
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2472
Country	:	US
Telephone Number	:	704-375-2822
Fax Number	:

Provider Business Practice Location Address
First Line	:	1801 E 5TH ST
Second Line	:	SUITE 108-B
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2472
Country	:	US
Telephone Number	:	704-375-2822
Fax Number	:

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	11/27/2007

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