Provider Demographics
NPI:1881762607
Name:GREEN, CAROL E (LIC AC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3163
Mailing Address - Country:US
Mailing Address - Phone:781-467-1245
Mailing Address - Fax:
Practice Address - Street 1:DEDHAM HEALTH ATHLETIC COMPLEX
Practice Address - Street 2:200 PROVIDENCE HIGHWAY
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026
Practice Address - Country:US
Practice Address - Phone:781-467-1245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA209484171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist