MEDICARE: DEXTER GREEN MCAP, CCJAP, ICRCADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ADC-010386-2015	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ADC-005091-2014	OTHER	FL	CCJAP
2	803591	OTHER	FL	ICRC-ADC
3	ADC-010386-2015	OTHER	FL	MCAP

General Provider Information

NPI Number	:	1285189118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEXTER GREEN MCAP, CCJAP, ICRCADC

Provider Business Mailing Address
First Line	:	2901 CLEVELAND ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-2930
Country	:	US
Telephone Number	:	973-510-3703
Fax Number	:

Provider Business Practice Location Address
First Line	:	15485 EAGLE NEST LN
Second Line	:	SUITE 210
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-2247
Country	:	US
Telephone Number	:	973-510-3703
Fax Number	:

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

Provider Enumeration Date	:	08/21/2016
Last Update Date	:	08/21/2016

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