Provider Demographics
NPI:1386972628
Name:GREEN, STACIE DIANE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:DIANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 HARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CLEMENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-3606
Mailing Address - Country:US
Mailing Address - Phone:609-502-8609
Mailing Address - Fax:
Practice Address - Street 1:1315 WINDRIM AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-2710
Practice Address - Country:US
Practice Address - Phone:609-502-8609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-25
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health