Provider Demographics
NPI:1144521188
Name:GREEN, VIRGINA SELLARS (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:VIRGINA
Middle Name:SELLARS
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:930 FOLLY RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3938
Mailing Address - Country:US
Mailing Address - Phone:843-314-5434
Mailing Address - Fax:843-277-6237
Practice Address - Street 1:43 POPLAR ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-3736
Practice Address - Country:US
Practice Address - Phone:910-512-5488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8848235Z00000X
SC5467235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA1449Medicaid