Provider Demographics
NPI:1548036072
Name:GREEN, NOEL (LSW)
Entity type:Individual
Prefix:
First Name:NOEL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11827 SOUTH LASALLE STREET
Mailing Address - Street 2:#3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628
Mailing Address - Country:US
Mailing Address - Phone:312-818-0497
Mailing Address - Fax:
Practice Address - Street 1:25 E WASHINGTON ST STE 1835
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1836
Practice Address - Country:US
Practice Address - Phone:312-940-3655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.112230104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362167937015Medicaid