Provider Demographics
NPI:1447474655
Name:GREEN, ELICIA A (MED)
Entity type:Individual
Prefix:
First Name:ELICIA
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 JOHNSON ST
Mailing Address - Street 2:APT. 2L
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-1807
Mailing Address - Country:US
Mailing Address - Phone:413-363-1354
Mailing Address - Fax:
Practice Address - Street 1:503 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-4101
Practice Address - Country:US
Practice Address - Phone:413-733-6661
Practice Address - Fax:413-733-7841
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health