Provider Demographics
NPI:1427359132
Name:GREEN, DWAYNE T (LCPC)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:T
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SHAWAN RD STE 101C
Mailing Address - Street 2:
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21030-1373
Mailing Address - Country:US
Mailing Address - Phone:443-982-0692
Mailing Address - Fax:443-982-0610
Practice Address - Street 1:5 SHAWAN RD STE 101C
Practice Address - Street 2:
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-1373
Practice Address - Country:US
Practice Address - Phone:443-982-0692
Practice Address - Fax:443-982-0616
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3757101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional