MEDICARE: MS. JUDITH H GREEN LCPC

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	CERT# 5603	IL
2	101YP2500X	Professional Counselor	180002622	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1623196	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1396860821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUDITH H GREEN LCPC

Provider Business Mailing Address
First Line	:	125 ACACIA CIRCLE
Second Line	:	#504
City	:	INDIAN HEAD PARK
State	:	IL
Zip	:	60525
Country	:	US
Telephone Number	:	630-841-5573
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 ACACIA CIRCLE
Second Line	:	#504
City	:	INDIAN HEAD PARK
State	:	IL
Zip	:	60525
Country	:	US
Telephone Number	:	630-841-5573
Fax Number	:

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	06/04/2024

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