Provider Demographics
NPI:1558868638
Name:GREEN, ASHANTI
Entity Type:Individual
Prefix:
First Name:ASHANTI
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 NELSON ST APT D
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06120-2070
Mailing Address - Country:US
Mailing Address - Phone:860-995-0787
Mailing Address - Fax:
Practice Address - Street 1:101 SOUTH ST FL 2
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06110-1967
Practice Address - Country:US
Practice Address - Phone:860-995-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician