Provider Demographics
NPI:1053980961
Name:GREEN, CHRISTINE JEWEL
Entity type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:JEWEL
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 1:77 CYMAN DR
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01013-3023
Mailing Address - Country:US
Mailing Address - Phone:413-374-7478
Mailing Address - Fax:
Practice Address - Street 1:77 CYMAN DR
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01013-3023
Practice Address - Country:US
Practice Address - Phone:413-374-7478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN96634164W00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse