MEDICARE: TANYA LAURETTE GREEN MSW

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	1041C0700X	Clinical Social Worker	34005094A	IN
2	1041C0700X	Clinical Social Worker	1531	OK

General Provider Information

NPI Number	:	1689632804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANYA LAURETTE GREEN MSW

Provider Business Mailing Address
First Line	:	310 E DUPONT RD
Second Line	:
City	:	FT WAYNE
State	:	IN
Zip	:	46825-2048
Country	:	US
Telephone Number	:	260-490-8110
Fax Number	:	260-490-7707

Provider Business Practice Location Address
First Line	:	310 E DUPONT RD
Second Line	:
City	:	FT WAYNE
State	:	IN
Zip	:	46825-2048
Country	:	US
Telephone Number	:	260-490-8110
Fax Number	:	260-490-7707

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

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/08/2007

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