Provider Demographics
NPI:1447501457
Name:GREEN, ELLYN DIANE (LMSW)
Entity type:Individual
Prefix:MS
First Name:ELLYN
Middle Name:DIANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2198
Mailing Address - Country:US
Mailing Address - Phone:607-798-7117
Mailing Address - Fax:607-798-0074
Practice Address - Street 1:18 BROAD ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2106
Practice Address - Country:US
Practice Address - Phone:607-217-0066
Practice Address - Fax:607-217-0069
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038634-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker