Provider Demographics
NPI:1467094128
Name:GREEN, ETHELDRA A
Entity Type:Individual
Prefix:
First Name:ETHELDRA
Middle Name:A
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 1:8116 BLENHEIM LN
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32312-6802
Mailing Address - Country:US
Mailing Address - Phone:850-345-2416
Mailing Address - Fax:
Practice Address - Street 1:10611 NW SR 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-3232
Practice Address - Country:US
Practice Address - Phone:850-643-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW13573104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLISW13573OtherSTATE OF FLORIDA DOH