Provider Demographics
NPI:1285189118
Name:GREEN, DEXTER (MCAP, CCJAP, ICRCADC)
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MCAP, CCJAP, ICRCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 CLEVELAND ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-2930
Mailing Address - Country:US
Mailing Address - Phone:973-510-3703
Mailing Address - Fax:
Practice Address - Street 1:15485 EAGLE NEST LN
Practice Address - Street 2:SUITE 210
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2247
Practice Address - Country:US
Practice Address - Phone:973-510-3703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-010386-2015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLADC-005091-2014OtherCCJAP
FL803591OtherICRC-ADC
FLADC-010386-2015OtherMCAP