MEDICARE: MR. ANDRE GREEN JR. 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	LPC24654	AZ

General Provider Information

NPI Number	:	1902567175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDRE GREEN JR. LPC

Provider Business Mailing Address
First Line	:	41318 W ALMIRA DR
Second Line	:
City	:	MARICOPA
State	:	AZ
Zip	:	85138-4492
Country	:	US
Telephone Number	:	919-491-2455
Fax Number	:

Provider Business Practice Location Address
First Line	:	41318 W ALMIRA DR
Second Line	:
City	:	MARICOPA
State	:	AZ
Zip	:	85138-4492
Country	:	US
Telephone Number	:	919-491-2455
Fax Number	:

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

Provider Enumeration Date	:	01/10/2022
Last Update Date	:	03/16/2026

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