Provider Demographics
NPI:1437842093
Name:GREEN, MONIQUE
Entity Type:Individual
Prefix:
First Name:MONIQUE
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 1:5760 PATRIOT BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:AUSTINTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-1170
Mailing Address - Country:US
Mailing Address - Phone:330-953-0243
Mailing Address - Fax:
Practice Address - Street 1:920 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4218
Practice Address - Country:US
Practice Address - Phone:330-953-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.179965101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)