MEDICARE: PATRICIA GREEN LCSW

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	1041C0700X	Clinical Social Worker	44SC01374100	NJ

General Provider Information

NPI Number	:	1902293301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA GREEN LCSW

Provider Business Mailing Address
First Line	:	100 CREEK CROSSING BLVD
Second Line	:	SUITE 108
City	:	HAINESPORT
State	:	NJ
Zip	:	08036-2765
Country	:	US
Telephone Number	:	609-702-5880
Fax Number	:	609-702-5882

Provider Business Practice Location Address
First Line	:	100 CREEK CROSSING BLVD
Second Line	:	SUITE 108
City	:	HAINESPORT
State	:	NJ
Zip	:	08036-2765
Country	:	US
Telephone Number	:	609-702-5880
Fax Number	:	609-702-5882

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

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	04/23/2015

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