Provider Demographics
NPI:1285308486
Name:GREEN, CONNIE (CDCA QBHS)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:CDCA QBHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2123
Mailing Address - Country:US
Mailing Address - Phone:937-599-4028
Mailing Address - Fax:
Practice Address - Street 1:586 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2123
Practice Address - Country:US
Practice Address - Phone:937-599-4028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty