Provider Demographics
NPI:1689780603
Name:GREEN, TIM (LMHC)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 AMBURY ST
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-7131
Mailing Address - Country:US
Mailing Address - Phone:239-321-0797
Mailing Address - Fax:239-390-0241
Practice Address - Street 1:9500 CORKSCREW PALMS CIR STE 3
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-3307
Practice Address - Country:US
Practice Address - Phone:239-321-0797
Practice Address - Fax:239-390-0241
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7986101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
38-3810234OtherTIN