Provider Demographics
NPI:1841387362
Name:GREEN, NATHAN (LISW)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1943 NEWARK GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-9169
Mailing Address - Country:US
Mailing Address - Phone:740-587-5252
Mailing Address - Fax:740-587-2571
Practice Address - Street 1:1943 NEWARK GRANVILLE RD
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-9169
Practice Address - Country:US
Practice Address - Phone:740-587-5252
Practice Address - Fax:740-587-2571
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI8029104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000376633OtherANTHEM BCBS
OH000000376633OtherANTHEM BCBS