Provider Demographics
NPI:1255153391
Name:GREEN, THEODORA K (LSW, CADC RMA, DVA)
Entity type:Individual
Prefix:MRS
First Name:THEODORA
Middle Name:K
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSW, CADC RMA, DVA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SIMPSON ST # 1A
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2459
Mailing Address - Country:US
Mailing Address - Phone:312-725-4088
Mailing Address - Fax:
Practice Address - Street 1:825 CHICAGO AVE FL 2A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2375
Practice Address - Country:US
Practice Address - Phone:312-725-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.111842101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health