Basic Information
| Provider Information | |||||||||
| NPI: | 1215069471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416530280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063498100 | ||||||||
| FaxNumber: | 6063498150 | ||||||||
| Practice Location | |||||||||
| Address1: | 906 E MOUNTAIN PKWY | ||||||||
| Address2: | |||||||||
| City: | SALYERSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 414658379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063498100 | ||||||||
| FaxNumber: | 6063498150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34005091A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 7100478310 | 05 | KY | MEDICAID |