Provider Demographics
NPI:1598199374
Name:GREEN, STEVEN ALAN
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:ALAN
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 1:107 CRANES ROOST CT
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-3650
Mailing Address - Country:US
Mailing Address - Phone:270-765-2605
Mailing Address - Fax:270-234-8572
Practice Address - Street 1:1311 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2621
Practice Address - Country:US
Practice Address - Phone:270-765-2605
Practice Address - Fax:270-234-8572
Is Sole Proprietor?:No
Enumeration Date:2013-08-28
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
KY2014-021106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor