Provider Demographics
NPI:1003490673
Name:GREEN, LAURA (LSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:TALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 W SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-6385
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-6385
Practice Address - Country:US
Practice Address - Phone:217-693-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health