Provider Demographics
NPI:1497429856
Name:GREEN, JUSTIN FENDELL (LCSWA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:FENDELL
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6480 KELMSCOT CT
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5674
Mailing Address - Country:US
Mailing Address - Phone:910-835-6895
Mailing Address - Fax:
Practice Address - Street 1:2525 RAEFORD RD STE 2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5091
Practice Address - Country:US
Practice Address - Phone:910-835-6895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0164091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical