Healthcare Provider Details

I. General information

NPI: 1891446753
Provider Name (Legal Business Name): IMAN GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14635 S HARRELLS FERRY RD STE 3A
BATON ROUGE LA
70816-2960
US

IV. Provider business mailing address

14635 S HARRELLS FERRY RD STE 3A
BATON ROUGE LA
70816-2960
US

V. Phone/Fax

Practice location:
  • Phone: 225-349-8984
  • Fax:
Mailing address:
  • Phone: 225-349-8984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPLC11304
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: