Provider Demographics
NPI:1568643484
Name:GREEN, LAVITA CRUTCHER (MSSW, LCSW)
Entity Type:Individual
Prefix:
First Name:LAVITA
Middle Name:CRUTCHER
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:LAVITA
Other - Middle Name:RENEE
Other - Last Name:CRUTCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW, LCSW
Mailing Address - Street 1:309 W MILLBROOK RD
Mailing Address - Street 2:STE 161
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-4385
Mailing Address - Country:US
Mailing Address - Phone:919-827-7061
Mailing Address - Fax:
Practice Address - Street 1:309 W MILLBROOK RD
Practice Address - Street 2:STE 161
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-4385
Practice Address - Country:US
Practice Address - Phone:919-827-7061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0058751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106813Medicaid