MEDICARE: ASHANTI 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	106S00000X	Behavior Technician		CT

General Provider Information

NPI Number	:	1558868638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHANTI GREEN

Provider Business Mailing Address
First Line	:	53 NELSON ST APT D
Second Line	:
City	:	HARTFORD
State	:	CT
Zip	:	06120-2070
Country	:	US
Telephone Number	:	860-995-0787
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 SOUTH ST FL 2
Second Line	:
City	:	WEST HARTFORD
State	:	CT
Zip	:	06110-1967
Country	:	US
Telephone Number	:	860-995-0787
Fax Number	:

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

Provider Enumeration Date	:	04/06/2018
Last Update Date	:	04/06/2018

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Directions to “ ASHANTI GREEN ” Practice Location

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