Basic Information
| Provider Information | |||||||||
| NPI: | 1790821866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN DOOR, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 TAYLOR ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024649200 | ||||||||
| FaxNumber: | 2024645730 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 TAYLOR ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024649200 | ||||||||
| FaxNumber: | 2024645730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLANCY | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2024649200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | ADD13912 | DC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 5237 | 01 | DC | HEALTHRIGHT (MCO) | OTHER | 287814 | 01 | DC | AMERIGROUP (MEDICAID MCO) | OTHER | 23349 | 01 | DC | CHARTERED HEALTH PLAN (MC | OTHER |