Provider Demographics
NPI:1619287190
Name:GREEN LIGHT COUNSELING, INC.
Entity Type:Organization
Organization Name:GREEN LIGHT COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:STRACK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:336-274-1237
Mailing Address - Street 1:301 N ELM ST
Mailing Address - Street 2:STE 801
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-2083
Mailing Address - Country:US
Mailing Address - Phone:336-274-1237
Mailing Address - Fax:336-274-1236
Practice Address - Street 1:301 N ELM ST
Practice Address - Street 2:STE 801
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-2083
Practice Address - Country:US
Practice Address - Phone:336-274-1237
Practice Address - Fax:336-274-1236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3410070Medicaid