Provider Demographics
NPI:1679748909
Name:GREEN, NICOLE E (LSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:E
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 BROAD ST APT 5
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8260
Mailing Address - Country:US
Mailing Address - Phone:330-252-7934
Mailing Address - Fax:
Practice Address - Street 1:2285 BENDEN DR
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2568
Practice Address - Country:US
Practice Address - Phone:330-264-9029
Practice Address - Fax:330-263-7251
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS00284321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical