Provider Demographics
NPI:1467733311
Name:GREEN, MOLLY JANE (MA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 UNION RD STE 225
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1093
Mailing Address - Country:US
Mailing Address - Phone:314-730-6787
Mailing Address - Fax:314-730-6585
Practice Address - Street 1:4121 UNION RD STE 225
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1093
Practice Address - Country:US
Practice Address - Phone:314-730-6787
Practice Address - Fax:314-730-6585
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180007619101YP2500X
MO2018029026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional