Provider Demographics
NPI:1306512132
Name:GREEN, COREY MATTHEW (PEER SUPPORTER)
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:MATTHEW
Last Name:GREEN
Suffix:
Gender:M
Credentials:PEER SUPPORTER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-2525
Mailing Address - Country:US
Mailing Address - Phone:614-276-4840
Mailing Address - Fax:
Practice Address - Street 1:1034 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2525
Practice Address - Country:US
Practice Address - Phone:614-276-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0002753175T00000X
OH180368101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist