MEDICARE: DWAYNE T 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	101YP2500X	Professional Counselor	LC3757	MD
2	101YM0800X	Mental Health Counselor	LC3757	MD

General Provider Information

NPI Number	:	1427359132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DWAYNE T GREEN LCPC

Provider Business Mailing Address
First Line	:	5 SHAWAN RD STE 101C
Second Line	:
City	:	HUNT VALLEY
State	:	MD
Zip	:	21030-1373
Country	:	US
Telephone Number	:	443-982-0692
Fax Number	:	443-982-0610

Provider Business Practice Location Address
First Line	:	5 SHAWAN RD STE 101C
Second Line	:
City	:	HUNT VALLEY
State	:	MD
Zip	:	21030-1373
Country	:	US
Telephone Number	:	443-982-0692
Fax Number	:	443-982-0616

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

Provider Enumeration Date	:	11/11/2010
Last Update Date	:	02/13/2019

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