Provider Demographics
NPI:1639171515
Name:GREEN, EDWARD A (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:ED
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:4018 MEADOWGOLD LN
Mailing Address - Street 2:SUITE 125
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77345-1008
Mailing Address - Country:US
Mailing Address - Phone:832-622-2386
Mailing Address - Fax:
Practice Address - Street 1:507 N SAM HOUSTON PKWY E
Practice Address - Street 2:SUITE 125
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77060-4021
Practice Address - Country:US
Practice Address - Phone:832-622-2386
Practice Address - Fax:800-434-4305
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX80552WOtherBCBS TEXAS
TX037320101Medicaid
TX037320101Medicaid