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General NPI Number Information
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NPI Number | 1235492711
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Entity Type | Organization
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Legal Business Name | GREEN LINE WELLNESS PLLC
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Dates
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Enumeration Date | 06/20/2012
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Last Update Date | 07/04/2012
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Provider Practice Location Address
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Address Line | 714 LYNDON LN SUITE ONE
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City | LOUISVILLE
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State | KY
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Zip | 40222-4643
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Country | US
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Telephone | 502-509-7357
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Fax |
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Provider Business Mailing Address
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Address Line | 714 LYNDON LN SUITE ONE
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City | LOUISVILLE
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State | KY
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Zip | 40222-4643
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. LAURA LINEBARGER
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Credential | PSYD
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Telephone | 502-509-7357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1658
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License Number State | KY
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