MEDICARE: MS. MARY LOU GREEN LMSW MSW

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	104100000X	Social Worker	3045	SC

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	:	1629122395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY LOU GREEN LMSW MSW

Provider Business Mailing Address
First Line	:	PO BOX 8462
Second Line	:	1919 GADSDEN STREET
City	:	COLUMBIA
State	:	SC
Zip	:	29202-8462
Country	:	US
Telephone Number	:	803-779-5356
Fax Number	:	803-779-2135

Provider Business Practice Location Address
First Line	:	1919 GADSDEN ST
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29202-8462
Country	:	US
Telephone Number	:	803-779-5356
Fax Number	:	803-779-2135

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

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	07/08/2007

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