Provider Demographics
NPI:1366716631
Name:GREEN, LISA M (LGSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 MORGAN ELLIS WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-1445
Mailing Address - Country:US
Mailing Address - Phone:443-527-3418
Mailing Address - Fax:
Practice Address - Street 1:8640 RIDGELYS CHOICE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21236-3029
Practice Address - Country:US
Practice Address - Phone:410-268-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD173981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical