Healthcare Provider Details

I. General information

NPI: 1770528770
Provider Name (Legal Business Name): MARTHA G GREEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 S COLLEGE RD STE A
LAFAYETTE LA
70503
US

IV. Provider business mailing address

1105 S COLLEGE RD STE A
LAFAYETTE LA
70503
US

V. Phone/Fax

Practice location:
  • Phone: 337-232-9113
  • Fax: 337-232-0022
Mailing address:
  • Phone: 337-232-9113
  • Fax: 337-232-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number726
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: