Provider Demographics
NPI:1801395496
Name:GREEN, DEWAYNE C
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:C
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19333 VAN AKEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3579
Mailing Address - Country:US
Mailing Address - Phone:216-513-7223
Mailing Address - Fax:
Practice Address - Street 1:41641 N RIDGE RD STE B
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-1264
Practice Address - Country:US
Practice Address - Phone:440-324-7406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-08
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141205101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)