Provider Demographics
NPI:1508489949
Name:GREEN, NATHAN ANDREW (BS, PSYCHOLOGY)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ANDREW
Last Name:GREEN
Suffix:
Gender:M
Credentials:BS, PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5534
Mailing Address - Country:US
Mailing Address - Phone:321-236-1540
Mailing Address - Fax:
Practice Address - Street 1:3597 VEGA CREEK DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-8317
Practice Address - Country:US
Practice Address - Phone:321-437-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator