Provider Demographics
NPI:1013523059
Name:GREEN, SOMMER MAE
Entity Type:Individual
Prefix:
First Name:SOMMER
Middle Name:MAE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4216 HUNTING HAWK DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-7040
Mailing Address - Country:US
Mailing Address - Phone:937-403-8350
Mailing Address - Fax:
Practice Address - Street 1:4216 HUNTING HAWK DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-7040
Practice Address - Country:US
Practice Address - Phone:937-403-8350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH173666101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)