Provider Demographics
NPI:1669810610
Name:GREEN, ERIC A (MA,FAA)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA,FAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2761
Mailing Address - Country:US
Mailing Address - Phone:973-627-0009
Mailing Address - Fax:973-627-3962
Practice Address - Street 1:92 BROADWAY STE B
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2733
Practice Address - Country:US
Practice Address - Phone:973-627-0009
Practice Address - Fax:973-627-3962
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-12
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00066900231H00000X
NJ669231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist