Provider Demographics
NPI:1316571904
Name:GREEN, INGRID C (LAC)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:INGRID
Other - Middle Name:C
Other - Last Name:GOTHMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1626
Mailing Address - Country:US
Mailing Address - Phone:738-654-5459
Mailing Address - Fax:
Practice Address - Street 1:25 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-1937
Practice Address - Country:US
Practice Address - Phone:973-865-4545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00455500101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor