Basic Information
| Provider Information | |||||||||
| NPI: | 1114196995 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER | ||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Practice Location | |||||||||
| Address1: | 843 MILLING AVE | ||||||||
| Address2: | IBERIA COMPREHENSIVE COMMUNITY HEALTH CENTER | ||||||||
| City: | LULING | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700704442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9857855800 | ||||||||
| FaxNumber: | 9857855811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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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 | 2084P0800X | DO.000157 | LA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1925349 | 05 | LA | MEDICAID | 1444642 | 05 | LA | MEDICAID | 1038024 | 05 | LA | MEDICAID |