MEDICARE: MR. EARL MARK GREEN M.A. LPC, NCC

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	101YP2500X	Professional Counselor	13051	TX

General Provider Information

NPI Number	:	1700409026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EARL MARK GREEN M.A. LPC, NCC

Provider Business Mailing Address
First Line	:	4621 COUNTRY CREEK DR APT 1044
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75236-1220
Country	:	US
Telephone Number	:	214-636-8956
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 COUNTRY CREEK DR APT 1044
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75236-1220
Country	:	US
Telephone Number	:	214-636-8956
Fax Number	:

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

Provider Enumeration Date	:	05/20/2020
Last Update Date	:	05/20/2020

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