Provider Demographics
NPI:1013246131
Name:GREEN, WILLIAM MACK (LCSW, LSAC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MACK
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSW, LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2305
Mailing Address - Country:US
Mailing Address - Phone:801-244-5166
Mailing Address - Fax:801-295-2618
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6162
Practice Address - Country:US
Practice Address - Phone:801-244-5166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-19
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4932942-6006101YA0400X
UT4932942-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)