Provider Demographics
NPI:1386846152
Name:GREEN, MYRA DUNFORD (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MYRA
Middle Name:DUNFORD
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 DRUMMONDS WAY
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23669-1061
Mailing Address - Country:US
Mailing Address - Phone:757-850-0077
Mailing Address - Fax:
Practice Address - Street 1:5900 LAKE WRIGHT DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-1871
Practice Address - Country:US
Practice Address - Phone:757-466-8683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040059541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417929639OtherGROUP NPI NUMBER