Provider Demographics
NPI:1760575625
Name:GREEN, ADRIANE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ADRIANE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:ADRIANE
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA CCC CLP
Mailing Address - Street 1:3085 DAUPHIN SQ CONNECTOR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36607-2517
Mailing Address - Country:US
Mailing Address - Phone:251-450-1110
Mailing Address - Fax:
Practice Address - Street 1:3905 JOHNS CREEK CT
Practice Address - Street 2:SUITE 250
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1265
Practice Address - Country:US
Practice Address - Phone:770-888-5221
Practice Address - Fax:770-623-5544
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006187235Z00000X
AL2575235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA293861298AMedicaid