Provider Demographics
NPI:1508623265
Name:GREEN, CARLYN MAIA (LGPC)
Entity Type:Individual
Prefix:
First Name:CARLYN
Middle Name:MAIA
Last Name:GREEN
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 ASHBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:HALETHORPE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-3954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 YORK RD STE 706
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-6010
Practice Address - Country:US
Practice Address - Phone:443-901-6227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP14886101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional