Provider Demographics
NPI:1790031441
Name:GREEN, MARY T
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:GREEN
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 1:2419 ADAMSWAY DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-9076
Mailing Address - Country:US
Mailing Address - Phone:630-566-9337
Mailing Address - Fax:
Practice Address - Street 1:2419 ADAMSWAY DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60502-9076
Practice Address - Country:US
Practice Address - Phone:630-566-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-31
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide