Provider Demographics
NPI:1083794861
Name:GREEN, REBECCA ANN
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:35 SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03076
Mailing Address - Country:US
Mailing Address - Phone:617-549-9711
Mailing Address - Fax:
Practice Address - Street 1:77 E MERRIMACK ST
Practice Address - Street 2:SOUTH BAY MENTAL HEALTH CENTER
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-1251
Practice Address - Country:US
Practice Address - Phone:978-453-6800
Practice Address - Fax:978-453-6767
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1131471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP23744Medicare ID - Type Unspecified