Basic Information
| Provider Information | |||||||||
| NPI: | 1770238156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10102 COUNTRY CLUB RD SE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215028339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017772405 | ||||||||
| FaxNumber: | 3017220850 | ||||||||
| Practice Location | |||||||||
| Address1: | 10102 COUNTRY CLUB RD SE | ||||||||
| Address2: | |||||||||
| City: | CUMBERLAND | ||||||||
| State: | MD | ||||||||
| PostalCode: | 215028339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017772290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2022 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AC004353 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.