Provider Demographics
NPI:1508822628
Name:GREEN, MARVIN L (LPC)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 FOX CHASE DR
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-5413
Mailing Address - Country:US
Mailing Address - Phone:843-830-2979
Mailing Address - Fax:843-572-6992
Practice Address - Street 1:179 FOX CHASE DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5413
Practice Address - Country:US
Practice Address - Phone:843-830-2979
Practice Address - Fax:843-572-6992
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional