Provider Demographics
NPI:1740565134
Name:GREEN-DAVIS, VENESSA
Entity Type:Individual
Prefix:MRS
First Name:VENESSA
Middle Name:
Last Name:GREEN-DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 CHATSWORTH AVENUE
Mailing Address - Street 2:CHATSWORTH AVENUE SCHOOL
Mailing Address - City:MAMARONECK
Mailing Address - State:NY
Mailing Address - Zip Code:10538
Mailing Address - Country:US
Mailing Address - Phone:914-220-3000
Mailing Address - Fax:
Practice Address - Street 1:34 CHATSWORTH AVENUE
Practice Address - Street 2:CHATSWORTH AVENUE SCHOOL
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538
Practice Address - Country:US
Practice Address - Phone:914-220-3509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1326195637171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01395326Medicaid