Basic Information
| Provider Information | |||||||||
| NPI: | 1023138484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | DORIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417153 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022417153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5189528140 | ||||||||
| FaxNumber: | 5189528287 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121803440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182745143 | ||||||||
| FaxNumber: | 5182731350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2007 | ||||||||
| LastUpdateDate: | 07/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 01420800 | 05 | NY | MEDICAID |