Provider Demographics
NPI:1679804504
Name:GREEN, MARTINA R (MHC)
Entity type:Individual
Prefix:MS
First Name:MARTINA
Middle Name:R
Last Name:GREEN
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-1902
Mailing Address - Country:US
Mailing Address - Phone:508-358-2657
Mailing Address - Fax:508-524-2276
Practice Address - Street 1:325 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1129
Practice Address - Country:US
Practice Address - Phone:508-358-2657
Practice Address - Fax:508-524-2276
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA930101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health