Provider Demographics
NPI:1134697360
Name:GREEN, ROBERT
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2692 CLAREDON TRCE NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6186
Mailing Address - Country:US
Mailing Address - Phone:631-553-7131
Mailing Address - Fax:
Practice Address - Street 1:9 CEDAR ST
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4103
Practice Address - Country:US
Practice Address - Phone:631-553-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor