Provider Demographics
NPI:1255158044
Name:GREEN, COLLEEN MARY
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
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 1:855 HUNTINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5233
Mailing Address - Country:US
Mailing Address - Phone:847-909-6295
Mailing Address - Fax:
Practice Address - Street 1:964 SPAFFORD ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1459
Practice Address - Country:US
Practice Address - Phone:847-838-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005927235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist