Provider Demographics
NPI:1053926618
Name:GREEN, NICOLE CAMILLE (MA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CAMILLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 ARTHUR AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-4020
Mailing Address - Country:US
Mailing Address - Phone:401-451-1651
Mailing Address - Fax:
Practice Address - Street 1:33 ARTHUR AVE APT 20
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-4020
Practice Address - Country:US
Practice Address - Phone:401-451-1651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health