Provider Demographics
NPI:1639147556
Name:DOUGLAS-GREEN, AMY K (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:K
Last Name:DOUGLAS-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 1:1650 HWY 18 SOUTH
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NC
Mailing Address - Zip Code:28675-9198
Mailing Address - Country:US
Mailing Address - Phone:336-372-4095
Mailing Address - Fax:828-262-5687
Practice Address - Street 1:1650 HWY 18 SOUTH
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:NC
Practice Address - Zip Code:28675-9198
Practice Address - Country:US
Practice Address - Phone:336-372-4095
Practice Address - Fax:828-262-5687
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0051621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106218Medicaid
NC186136OtherMEDCOST
NC2873925Medicare ID - Type UnspecifiedPROVIDER ID #