Provider Demographics
NPI:1902567175
Name:GREEN, ANDRE JR
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1923 BLACKWOLF RUN LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5405
Mailing Address - Country:US
Mailing Address - Phone:919-491-2455
Mailing Address - Fax:
Practice Address - Street 1:1822 NC- 54
Practice Address - Street 2:UNIT 100
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-474-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health