Provider Demographics
NPI:1851791826
Name:GREEN, ROBERT (LPCA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4680 BROWNSBORO RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3428
Mailing Address - Country:US
Mailing Address - Phone:336-896-9771
Mailing Address - Fax:
Practice Address - Street 1:4680 BROWNSBORO RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3428
Practice Address - Country:US
Practice Address - Phone:336-896-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10982101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health