Provider Demographics
NPI:1780771147
Name:GREEN, M MARIE (DSW/LCSW)
Entity type:Individual
Prefix:DR
First Name:M
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:DSW/LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5582 S 1750 E
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4388
Mailing Address - Country:US
Mailing Address - Phone:801-476-8885
Mailing Address - Fax:
Practice Address - Street 1:5582 S 1750 E
Practice Address - Street 2:CRYSTAL CACOON
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4388
Practice Address - Country:US
Practice Address - Phone:801-394-3234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12722135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT82561OtherPEHP
UT82561OtherPEHP
UT003113008Medicare ID - Type Unspecified