Basic Information
| Provider Information | |||||||||
| NPI: | 1467658658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | TERI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREEN | ||||||||
| OtherFirstName: | THERESA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4220 N 20TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850155101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022797655 | ||||||||
| FaxNumber: | 6022415756 | ||||||||
| Practice Location | |||||||||
| Address1: | 5701 W TALAVI BLVD | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234868202 | ||||||||
| FaxNumber: | 6234862739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2007 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LCSW-12722 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | LMSW-11867 | AZ | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | LCSW-12722 | 01 | AZ | STATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS | OTHER | LMSW-11867 | 01 | AZ | BOARD OF BEHAVIORAL HEALTH EXAMINERS | OTHER |