Basic Information
| Provider Information | |||||||||
| NPI: | 1346658929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.ED., LPC-CR | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 781625 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 399 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558550 | ||||||||
| FaxNumber: | 6143558593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2014 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.1200451-CR | OH | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | C.1200451 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |