Provider Demographics
NPI:1740200799
Name:GREEN, ILENE J (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:J
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:ILENE
Other - Middle Name:
Other - Last Name:POTASNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:631 D ST NW
Mailing Address - Street 2:UNIT 844
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20004-2956
Mailing Address - Country:US
Mailing Address - Phone:202-745-8000
Mailing Address - Fax:
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:DEPT OF AUDIOLOGY AND SPEECH PATHOLOGY (126)
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist