Provider Demographics
NPI:1740908326
Name:GREEN, MARTHA L
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:L
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 1:3 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WELDON
Mailing Address - State:NC
Mailing Address - Zip Code:27890-1520
Mailing Address - Country:US
Mailing Address - Phone:252-676-5701
Mailing Address - Fax:252-678-8015
Practice Address - Street 1:3 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WELDON
Practice Address - State:NC
Practice Address - Zip Code:27890-1520
Practice Address - Country:US
Practice Address - Phone:252-676-5701
Practice Address - Fax:252-678-8015
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2081-2303-01175T00000X
NC5005077101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5005077Medicaid