Provider Demographics
NPI:1831721026
Name:GREEN, PAMELA MARIE
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARIE
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 1:2109 BOSTON PIKE # SR227
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-7218
Mailing Address - Country:US
Mailing Address - Phone:513-593-3033
Mailing Address - Fax:
Practice Address - Street 1:2109 BOSTON PIKE # SR227
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-7218
Practice Address - Country:US
Practice Address - Phone:513-593-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-06
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39004220A101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300035607Medicaid