Healthcare Provider Details

I. General information

NPI: 1467658658
Provider Name (Legal Business Name): TERI GREEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: THERESA GREEN LCSW

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 W TALAVI BLVD SUITE 180
GLENDALE AZ
85306-1886
US

IV. Provider business mailing address

4220 N 20TH AVE
PHOENIX AZ
85015-5101
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-8202
  • Fax: 623-486-2739
Mailing address:
  • Phone: 602-279-7655
  • Fax: 602-241-5756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW-12722
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMSW-11867
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: