Provider Demographics
NPI:1780612093
Name:GREEN, KAREN SUE (MSW, LISW)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:SUE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSW, LISW
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:SUE
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LISW
Mailing Address - Street 1:65 MESSIMER DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-3626
Mailing Address - Country:US
Mailing Address - Phone:740-788-3400
Mailing Address - Fax:740-788-3401
Practice Address - Street 1:65 MESSIMER DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-3626
Practice Address - Country:US
Practice Address - Phone:740-788-3400
Practice Address - Fax:740-788-3401
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00053831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSW20461Medicare ID - Type Unspecified