Provider Demographics
NPI:1144792995
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 1:4037 176TH PL
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 N LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6606
Practice Address - Country:US
Practice Address - Phone:815-727-6958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical