MEDICARE: MR. JUSTIN O GREEN LPC

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	P0311042	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5S755	OTHER	AR	BLUECROSS PROVIDER NUMBER

General Provider Information

NPI Number	:	1881613503
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN O GREEN LPC

Provider Business Mailing Address
First Line	:	1022 HEATHERDOWN
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-5015
Country	:	US
Telephone Number	:	870-232-1823
Fax Number	:

Provider Business Practice Location Address
First Line	:	1022 HEATHERDOWN
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-5015
Country	:	US
Telephone Number	:	870-232-1823
Fax Number	:

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

Provider Enumeration Date	:	07/19/2006
Last Update Date	:	10/18/2023

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