Provider Demographics
NPI:1376822445
Name:GREEN, DOUGLAS (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 REDMON LN
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-4957
Mailing Address - Country:US
Mailing Address - Phone:571-208-2056
Mailing Address - Fax:703-649-6471
Practice Address - Street 1:8715 PLANTATION LN
Practice Address - Street 2:STE 301 A
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-8323
Practice Address - Country:US
Practice Address - Phone:571-232-6506
Practice Address - Fax:703-649-6471
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701005090101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor