Provider Demographics
NPI:1184182206
Name:GREEN, ASHLEY DISEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DISEAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2325
Mailing Address - Country:US
Mailing Address - Phone:919-956-4000
Mailing Address - Fax:919-667-2322
Practice Address - Street 1:1301 FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2398
Practice Address - Country:US
Practice Address - Phone:919-956-4000
Practice Address - Fax:919-667-2322
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0116941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid