Provider Demographics
NPI:1538120480
Name:GREEN, ROBERT LAWRENCE (LCMHC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:LAWRENCE
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 SHELBURNE ROAD
Mailing Address - Street 2:SUITE D 4
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7753
Mailing Address - Country:US
Mailing Address - Phone:802-658-2390
Mailing Address - Fax:
Practice Address - Street 1:1233 SHELBURNE ROAD
Practice Address - Street 2:SUITE D 4
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7753
Practice Address - Country:US
Practice Address - Phone:802-658-2390
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0680000015101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1006850Medicaid
NH30423776Medicaid
347880OtherMVP
VT5062OtherBCBS