Healthcare Provider Details

I. General information

NPI: 1376602110
Provider Name (Legal Business Name): DARYL GREEN LPC LMFT NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 10/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 FLORENCE RD SUITE 10
KILLEEN TX
76541-8523
US

IV. Provider business mailing address

PO BOX 416
TEMPLE TX
76503-0416
US

V. Phone/Fax

Practice location:
  • Phone: 254-526-5389
  • Fax: 254-526-4853
Mailing address:
  • Phone: 254-774-8806
  • Fax: 254-774-9672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13560
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4672
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: