Provider Demographics
NPI:1164916599
Name:GREEN, PAYTON DENAE
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:DENAE
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 1:553 GLENDORA AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1903
Mailing Address - Country:US
Mailing Address - Phone:240-605-5330
Mailing Address - Fax:
Practice Address - Street 1:333 S MAIN ST STE 607
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44308-1228
Practice Address - Country:US
Practice Address - Phone:234-334-3293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator