Healthcare Provider Details

I. General information

NPI: 1629130190
Provider Name (Legal Business Name): PATRICIA ELLEN GREEN MA ., LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 CALLE MEDICO STE 5
SANTA FE NM
87505-4705
US

IV. Provider business mailing address

PO BOX 5887
SANTA FE NM
87502-5887
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-2959
  • Fax:
Mailing address:
  • Phone: 505-577-2959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0075291
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: