Provider Demographics
NPI:1063202539
Name:GREEN, LENDELL
Entity type:Individual
Prefix:
First Name:LENDELL
Middle Name:
Last Name:GREEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 E JENKINS AVE
Mailing Address - Street 2:NICOLEGADE@CSU.FULLERTON.EDU
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43207-4322
Mailing Address - Country:US
Mailing Address - Phone:380-230-5330
Mailing Address - Fax:714-833-1426
Practice Address - Street 1:707 E JENKINS AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207
Practice Address - Country:US
Practice Address - Phone:380-230-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator