Provider Demographics
NPI:1992042014
Name:GREEN, RAECHAL E (MA)
Entity Type:Individual
Prefix:
First Name:RAECHAL
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3084 HILLSIDE TRL
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-4791
Mailing Address - Country:US
Mailing Address - Phone:330-328-3344
Mailing Address - Fax:
Practice Address - Street 1:3518 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-1951
Practice Address - Country:US
Practice Address - Phone:216-741-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178007560101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional