Provider Demographics
NPI:1457954125
Name:GREEN, MADELEINE
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
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 1:1205 VETERANS WAY
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3563
Mailing Address - Country:US
Mailing Address - Phone:317-775-9901
Mailing Address - Fax:
Practice Address - Street 1:5638 PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-5042
Practice Address - Country:US
Practice Address - Phone:888-714-1927
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-20-134075106S00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician