Provider Demographics
NPI:1386035566
Name:JIM GREEN COUNSELING, P.A.
Entity Type:Organization
Organization Name:JIM GREEN COUNSELING, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-941-1663
Mailing Address - Street 1:47 MAIN STREET
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401
Mailing Address - Country:US
Mailing Address - Phone:207-941-1663
Mailing Address - Fax:207-941-0077
Practice Address - Street 1:47 MAIN STREET
Practice Address - Street 2:SUITE 230
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-941-1663
Practice Address - Fax:207-941-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC5061101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM667001Medicare PIN