Provider Demographics
NPI:1407080690
Name:GREEN, TARA TZIPORA
Entity Type:Individual
Prefix:
First Name:TARA TZIPORA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 REMOUNT ROAD
Mailing Address - Street 2:SUITE C-1 #562
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:704-709-5065
Mailing Address - Fax:
Practice Address - Street 1:1022 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3209
Practice Address - Country:US
Practice Address - Phone:973-694-2345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NJ44SL05320500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional