Provider Demographics
NPI:1619335916
Name:GREEN, JOHAN (LADC)
Entity type:Individual
Prefix:
First Name:JOHAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 FALLS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:VT
Mailing Address - Zip Code:05679-4438
Mailing Address - Country:US
Mailing Address - Phone:603-593-2444
Mailing Address - Fax:
Practice Address - Street 1:1135 FALLS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:VT
Practice Address - Zip Code:05679-4438
Practice Address - Country:US
Practice Address - Phone:603-593-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18658101YA0400X
390200000X
VT151.0134089101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty