Basic Information
| Provider Information | |||||||||
| NPI: | 1801925193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN DOOR BEHAVIORAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 TAYLOR ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024649200 | ||||||||
| FaxNumber: | 2024645740 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 TAYLOR ST NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200115617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024649200 | ||||||||
| FaxNumber: | 2024645740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | BEBOUT | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2024649200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 251B00000X | N | Agencies | Case Management | 261QM0801X | 54000690 | DC | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM0855X | DC | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X | DC | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 057062300 | 05 | DC | MEDICAID | 036561200 | 05 | DC | MEDICAID |