Basic Information
| Provider Information | |||||||||
| NPI: | 1033649157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | TANYATTA | ||||||||
| MiddleName: | DEANNA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 DOCK LANDING RD | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233211834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575373720 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 222 W 19TH ST | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235172218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7576227017 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.