Provider Demographics
NPI:1285963173
Name:GREEN, ERNESTINE (MFT, LAC)
Entity type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MFT, LAC
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT, LAC
Mailing Address - Street 1:PO BOX 1560
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08099-5560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:553 BECKETT RD
Practice Address - Street 2:
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1565
Practice Address - Country:US
Practice Address - Phone:856-677-8535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-23
Last Update Date:2019-12-10
Deactivation Date:2017-03-16
Deactivation Code:
Reactivation Date:2019-11-07
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist