Provider Demographics
NPI:1902186315
Name:GREEN, RODERICA (MA, MPH, CAD)
Entity Type:Individual
Prefix:
First Name:RODERICA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA, MPH, CAD
Other - Prefix:
Other - First Name:ERICA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1431 N CLAREMONT AVE
Mailing Address - Street 2:2ND FLOOR PAVILLION
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1702
Mailing Address - Country:US
Mailing Address - Phone:312-491-7268
Mailing Address - Fax:
Practice Address - Street 1:1431 N CLAREMONT AVE
Practice Address - Street 2:2ND FLOOR PAVILLION
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1702
Practice Address - Country:US
Practice Address - Phone:312-491-7268
Practice Address - Fax:312-491-5453
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)