Provider Demographics
NPI:1649879982
Name:GREEN, VERONICIA S
Entity type:Individual
Prefix:
First Name:VERONICIA
Middle Name:S
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 1:1350 N 55TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53208-2101
Mailing Address - Country:US
Mailing Address - Phone:414-334-0630
Mailing Address - Fax:
Practice Address - Street 1:2821 N VEL R PHILLIPS AVE STE 131
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2370
Practice Address - Country:US
Practice Address - Phone:414-431-8322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18955-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)