Provider Demographics
NPI:1083174361
Name:GREEN, TAMARA C
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 NEW ORLEANS WAY APT SUITE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8689
Mailing Address - Country:US
Mailing Address - Phone:770-309-0847
Mailing Address - Fax:866-397-3046
Practice Address - Street 1:1650 NEW ORLEANS WAY APT SUITE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-8689
Practice Address - Country:US
Practice Address - Phone:770-309-0847
Practice Address - Fax:866-397-3046
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty