Provider Demographics
NPI:1245225952
Name:GREEN, CHARLES MCCLURE (LICENS PSYCHOLOGIST)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MCCLURE
Last Name:GREEN
Suffix:
Gender:M
Credentials:LICENS PSYCHOLOGIST
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:RR 2 BOX 233B
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLARE
Mailing Address - State:WV
Mailing Address - Zip Code:26408-9719
Mailing Address - Country:US
Mailing Address - Phone:304-622-6404
Mailing Address - Fax:304-622-6404
Practice Address - Street 1:RT 20
Practice Address - Street 2:
Practice Address - City:QUIET DELL
Practice Address - State:WV
Practice Address - Zip Code:26408
Practice Address - Country:US
Practice Address - Phone:304-622-6404
Practice Address - Fax:304-622-6404
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV397103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist