Provider Demographics
NPI:1154478188
Name:GREEN, MAXINE A (LICSW)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 519
Mailing Address - Street 2:
Mailing Address - City:STEPHENTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:12168-0519
Mailing Address - Country:US
Mailing Address - Phone:518-733-9714
Mailing Address - Fax:
Practice Address - Street 1:60 COTTAGE ST
Practice Address - Street 2:MAIN ST HUMAN RESOURCES BRIEN CENTER
Practice Address - City:GREAT BARRINGTON
Practice Address - State:MA
Practice Address - Zip Code:01230-1302
Practice Address - Country:US
Practice Address - Phone:413-528-9155
Practice Address - Fax:413-528-8187
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1073941041C0700X
NYPR020946-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA31728OtherHEALTH NEW ENGLAND
MAP20789Medicare ID - Type UnspecifiedMEDICARE