Provider Demographics
NPI:1083368443
Name:GREEN, KATIE MARIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
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 1:4131 SPICEWOOD SPRINGS RD STE M2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8652
Mailing Address - Country:US
Mailing Address - Phone:270-316-8424
Mailing Address - Fax:
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD STE M2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8652
Practice Address - Country:US
Practice Address - Phone:270-316-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX82840101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health