Healthcare Provider Details

I. General information

NPI: 1558844654
Provider Name (Legal Business Name): TINA GREENE LIAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15317 W BELL RD STE 106
SURPRISE AZ
85374-3901
US

IV. Provider business mailing address

3033 N CENTRAL AVE STE 145
PHOENIX AZ
85012-2808
US

V. Phone/Fax

Practice location:
  • Phone: 480-964-2273
  • Fax:
Mailing address:
  • Phone: 623-583-3001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLIAC-155434
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: