Provider Demographics
NPI:1114403847
Name:GREEN, PATRICIA DWYER
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DWYER
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CANTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-3507
Mailing Address - Country:US
Mailing Address - Phone:617-696-8341
Mailing Address - Fax:
Practice Address - Street 1:104 CANTON AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3507
Practice Address - Country:US
Practice Address - Phone:617-696-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1020291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical