Healthcare Provider Details

I. General information

NPI: 1861848723
Provider Name (Legal Business Name): JUDITH GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JUDY M GREEN JUDITH MARCUM

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W SOUTHERN AVE STE E
MESA AZ
85210-5018
US

IV. Provider business mailing address

PO BOX 3403
TEMPE AZ
85280-3403
US

V. Phone/Fax

Practice location:
  • Phone: 602-753-8036
  • Fax:
Mailing address:
  • Phone: 602-753-8902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-18967
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: