Provider Demographics
NPI:1396792396
Name:GREEN, GARY (LCSW-C)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5750 PARK HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3930
Mailing Address - Country:US
Mailing Address - Phone:410-466-9200
Mailing Address - Fax:
Practice Address - Street 1:5750 PARK HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3930
Practice Address - Country:US
Practice Address - Phone:410-466-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical