Healthcare Provider Details

I. General information

NPI: 1538705140
Provider Name (Legal Business Name): BREANNA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 BLUEBONNET BLVD
BATON ROUGE LA
70809-9661
US

IV. Provider business mailing address

9015 PECAN TREE DR
BATON ROUGE LA
70810-7041
US

V. Phone/Fax

Practice location:
  • Phone: 225-223-6968
  • Fax:
Mailing address:
  • Phone: 225-371-0058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number9815
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: