Healthcare Provider Details

I. General information

NPI: 1386331148
Provider Name (Legal Business Name): SEAN GREEN LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 S ASH AVE
TEMPE AZ
85281-2812
US

IV. Provider business mailing address

PO BOX 5002 MAIL STOP 1602
TEMPE AZ
85280
US

V. Phone/Fax

Practice location:
  • Phone: 480-858-2143
  • Fax:
Mailing address:
  • Phone: 480-858-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-19571
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: