Provider Demographics
NPI:1720647290
Name:GREEN, GAIL (LSW)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5726 SOUTHWYCK BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1587
Mailing Address - Country:US
Mailing Address - Phone:419-214-9366
Mailing Address - Fax:
Practice Address - Street 1:5726 SOUTHWYCK BLVD STE 140
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1587
Practice Address - Country:US
Practice Address - Phone:419-214-9366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251S00000XAgenciesCommunity/Behavioral Health