Active NPI
Etheldra A Green
- Social Worker
- Bristol, FL
National Provider Identifier
1467094128
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Social Worker
- License
- ISW13573
- Practice address
- 10611 NW Sr 20
Bristol, FL 32321-3232 - Phone
- (850) 643-1033
- NPI assigned
- Oct 15, 2019
- Last updated
- Oct 15, 2019
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Social Worker | 104100000X | ISW13573 | FL | Primary |
Addresses
Primary practice location
10611 NW Sr 20
Bristol, FL 32321-3232
Mailing address
8116 Blenheim LN
Tallahassee, FL 32312-6802
Phone (850) 345-2416
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| ISW13573 | Other | FL | STATE OF FLORIDA DOH |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ISW13573 | FL | MD | Social Worker |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1571097600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1571097600000",
"number": "1467094128",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "8116 BLENHEIM LN",
"city": "TALLAHASSEE",
"state": "FL",
"postal_code": "323126802",
"telephone_number": "850-345-2416"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10611 NW SR 20",
"city": "BRISTOL",
"state": "FL",
"postal_code": "323213232",
"telephone_number": "850-643-1033"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GREEN",
"first_name": "ETHELDRA",
"middle_name": "A",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2019-10-15",
"last_updated": "2019-10-15",
"status": "A"
},
"taxonomies": [
{
"code": "104100000X",
"taxonomy_group": "",
"desc": "Social Worker",
"state": "FL",
"license": "ISW13573",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "STATE OF FLORIDA DOH",
"identifier": "ISW13573",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Bristol, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 15, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.