Provider Demographics
NPI:1558794768
Name:GREEN, ADAM ADAIR (MFTI)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:ADAIR
Last Name:GREEN
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9674
Mailing Address - Country:US
Mailing Address - Phone:385-212-0106
Mailing Address - Fax:
Practice Address - Street 1:5698 W GLEN EAGLE DR
Practice Address - Street 2:
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84128-4013
Practice Address - Country:US
Practice Address - Phone:801-969-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist