Provider Demographics
NPI:1912623505
Name:GREEN, IESHA
Entity Type:Individual
Prefix:
First Name:IESHA
Middle Name:
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 1:255 TUSCAN RD APT 107
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3087
Mailing Address - Country:US
Mailing Address - Phone:862-271-5831
Mailing Address - Fax:
Practice Address - Street 1:255 TUSCAN RD APT 107
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3087
Practice Address - Country:US
Practice Address - Phone:862-271-5831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171400000XOther Service ProvidersHealth & Wellness Coach
No372600000XNursing Service Related ProvidersAdult Companion