Provider Demographics
NPI:1821300468
Name:GREEN, EDITH MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ZACHARY LN APT 3
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08620-2813
Mailing Address - Country:US
Mailing Address - Phone:614-975-8979
Mailing Address - Fax:
Practice Address - Street 1:31 E DARRAH LN
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-3763
Practice Address - Country:US
Practice Address - Phone:614-975-8979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00469000101YP2500X
OHC 0500769101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional