Provider Demographics
NPI:1790042356
Name:GREEN, STELLA LOUISE (LCAS)
Entity Type:Individual
Prefix:MS
First Name:STELLA
Middle Name:LOUISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 COBURN PL APT 106
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-7971
Mailing Address - Country:US
Mailing Address - Phone:919-532-9855
Mailing Address - Fax:
Practice Address - Street 1:3826 BLAND RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6239
Practice Address - Country:US
Practice Address - Phone:919-872-1441
Practice Address - Fax:919-872-1445
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2020-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2908101YA0400X
NC2908 A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1790042356Medicaid