Basic Information
| Provider Information | |||||||||
| NPI: | 1255787354 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | NATHANIEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCASA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2023 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284016600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106322191 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2023 S 17TH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284016600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106322191 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2016 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCAS-3156 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.