MEDICARE: GREEN LIGHT COUNSELING, INC.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619287190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN LIGHT COUNSELING, INC.

Provider Business Mailing Address
First Line	:	301 N ELM ST
Second Line	:	STE 801
City	:	GREENSBORO
State	:	NC
Zip	:	27401-2083
Country	:	US
Telephone Number	:	336-274-1237
Fax Number	:	336-274-1236

Provider Business Practice Location Address
First Line	:	301 N ELM ST
Second Line	:	STE 801
City	:	GREENSBORO
State	:	NC
Zip	:	27401-2083
Country	:	US
Telephone Number	:	336-274-1237
Fax Number	:	336-274-1236

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MR. JASON W STRACK
Credential	:	LPC
Telephone Number	:	336-274-1237

Provider Enumeration Date	:	10/18/2010
Last Update Date	:	01/30/2012

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