Provider Demographics
NPI:1598439267
Name:GREEN, BRENDA DENISE (AC0356 CAA-DC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:DENISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:AC0356 CAA-DC
Other - Prefix:MRS
Other - First Name:BRENDA
Other - Middle Name:DENISE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 BRIGHTSEAT RD
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-4708
Mailing Address - Country:US
Mailing Address - Phone:301-209-5254
Mailing Address - Fax:
Practice Address - Street 1:425 BRIGHTSEAT RD
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4708
Practice Address - Country:US
Practice Address - Phone:301-209-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC0356101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDAC0356Medicaid