Basic Information
| Provider Information | |||||||||
| NPI: | 1447501457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ELLYN | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 BROAD STREET | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077987117 | ||||||||
| FaxNumber: | 6077980074 | ||||||||
| Practice Location | |||||||||
| Address1: | 18 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072170066 | ||||||||
| FaxNumber: | 6072170069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2012 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 038634-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.