Healthcare Provider Details

I. General information

NPI: 1992072730
Provider Name (Legal Business Name): PAT GREEN PH.D., CRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 N MARTIN LUTHER KING JR ST
NATCHEZ MS
39120-2826
US

IV. Provider business mailing address

917 MARTIN LUTHER KING, JR. ST.
NATCHEZ MS
39120
US

V. Phone/Fax

Practice location:
  • Phone: 908-361-9831
  • Fax: 601-445-0969
Mailing address:
  • Phone: 908-361-9831
  • Fax: 601-445-0969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number00015299
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: