Provider Demographics
NPI:1568507648
Name:GREEN, MARY JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-3001
Mailing Address - Country:US
Mailing Address - Phone:609-597-8366
Mailing Address - Fax:609-597-0086
Practice Address - Street 1:9 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2929
Practice Address - Country:US
Practice Address - Phone:609-276-6358
Practice Address - Fax:609-597-0086
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC052605001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ20-3711788OtherTAX ID NUMBER