Provider Demographics
NPI:1033221676
Name:GREEN, WADE M JR (MA, NCC, LCPC)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:M
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:MA, NCC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4665 PRESTANCIA PL APT 303
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-4131
Mailing Address - Country:US
Mailing Address - Phone:301-928-6045
Mailing Address - Fax:301-392-0306
Practice Address - Street 1:6100 RADIO STATION RD.
Practice Address - Street 2:
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646
Practice Address - Country:US
Practice Address - Phone:301-609-9887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2196101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD521450501Medicaid
MD521450500Medicaid
MD521450500Medicaid
DCG01516Medicare ID - Type Unspecified