Provider Demographics
NPI:1962619353
Name:GREEN, AMY JO (LSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6225 FRAZEYSBURG RD
Mailing Address - Street 2:
Mailing Address - City:NASHPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43830-9651
Mailing Address - Country:US
Mailing Address - Phone:740-452-0199
Mailing Address - Fax:
Practice Address - Street 1:1375 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-9511
Practice Address - Country:US
Practice Address - Phone:740-454-9766
Practice Address - Fax:740-588-6452
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0015240104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker