Provider Demographics
NPI:1598502320
Name:GREEN, CANDACE LAVERN (RESIDENT)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:LAVERN
Last Name:GREEN
Suffix:
Gender:F
Credentials:RESIDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CENTRE PORT CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-5453
Mailing Address - Country:US
Mailing Address - Phone:757-593-9971
Mailing Address - Fax:
Practice Address - Street 1:291 INDEPENDENCE BLVD BLDG 4
Practice Address - Street 2:
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5481
Practice Address - Country:US
Practice Address - Phone:757-593-9971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704016556101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health