Basic Information
| Provider Information | |||||||||
| NPI: | 1275151128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | JAY | ||||||||
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| Credential: | LCAS-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 FRANCISCAN TER APT H | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271277708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2405506452 | ||||||||
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| Practice Location | |||||||||
| Address1: | 665 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271012701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367258389 | ||||||||
| FaxNumber: | 3367256628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2020 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 26024 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.