MEDICARE: MS. TERI GREEN LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LCSW-12722	AZ
2	101YM0800X	Mental Health Counselor	LMSW-11867	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LCSW-12722	OTHER	AZ	STATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS
2	LMSW-11867	OTHER	AZ	BOARD OF BEHAVIORAL HEALTH EXAMINERS

General Provider Information

NPI Number	:	1467658658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERI GREEN LCSW

Provider Business Mailing Address
First Line	:	4220 N 20TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85015-5101
Country	:	US
Telephone Number	:	602-279-7655
Fax Number	:	602-241-5756

Provider Business Practice Location Address
First Line	:	5701 W TALAVI BLVD
Second Line	:	SUITE 180
City	:	GLENDALE
State	:	AZ
Zip	:	85306-1886
Country	:	US
Telephone Number	:	623-486-8202
Fax Number	:	623-486-2739

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	09/15/2011

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Directions to “ MS. TERI GREEN LCSW” Practice Location

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