Basic Information
| Provider Information | |||||||||
| NPI: | 1710452586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIGITTE GREEN, LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 287 W JOHNSTOWN RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432302732 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 287 W JOHNSTOWN RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432302732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143055102 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2018 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | BRIGITTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 6143953154 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0207723 | 05 | OH | MEDICAID |