=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750238051
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENTAL MANNA COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2026
-----------------------------------------------------
Last Update Date | 03/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41318 W ALMIRA DR
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-4492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-491-2455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41318 W ALMIRA DR
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-4492
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-491-2455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ANDRE DEZAN GREEN JR.
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 919-491-2455
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------