MEDICARE: MRS. CARRY L GREEN MA LMHP LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	2389	NE
2	101YP2500X	Professional Counselor	1316	NE
3	101YP2500X	Professional Counselor	LPC-17306	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	84002	OTHER	NE	BLUE CROSS BLUE SHIELD
2	234934	OTHER	NE	MIDLANDS CHOICE

General Provider Information

NPI Number	:	1447318282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARRY L GREEN MA LMHP LPC

Provider Business Mailing Address
First Line	:	3620 N 3RD ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2020
Country	:	US
Telephone Number	:	602-230-7373
Fax Number	:	602-230-5105

Provider Business Practice Location Address
First Line	:	9014 S CENTRAL AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85042-8304
Country	:	US
Telephone Number	:	602-230-7373
Fax Number	:	602-230-5105

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	09/15/2020

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