Healthcare Provider Details

I. General information

NPI: 1891978839
Provider Name (Legal Business Name): SHEILA M GREEN LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 MT VIEW DR
TWIN FALLS ID
83301-4319
US

IV. Provider business mailing address

595 MT VIEW DR
TWIN FALLS ID
83301-4319
US

V. Phone/Fax

Practice location:
  • Phone: 435-574-8016
  • Fax:
Mailing address:
  • Phone: 435-574-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-4469
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-3637
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: