Healthcare Provider Details

I. General information

NPI: 1558926204
Provider Name (Legal Business Name): ABIGAIL HEDY BLACKBURN GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2019
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6734 N 10TH AVE
PHOENIX AZ
85013-1008
US

IV. Provider business mailing address

6734 N 10TH AVE
PHOENIX AZ
85013-1008
US

V. Phone/Fax

Practice location:
  • Phone: 480-466-3119
  • Fax:
Mailing address:
  • Phone: 480-466-3119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: