Provider Demographics
NPI:1174975924
Name:GREEN, L'TANYA DENISE (LBSW)
Entity type:Individual
Prefix:
First Name:L'TANYA
Middle Name:DENISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:MS
Other - First Name:L'TANYA
Other - Middle Name:DENISE
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LBSW
Mailing Address - Street 1:1495 WOODLAKE LN
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7275
Mailing Address - Country:US
Mailing Address - Phone:734-657-4782
Mailing Address - Fax:
Practice Address - Street 1:4760 S PECOS RD STE 103-3
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-6038
Practice Address - Country:US
Practice Address - Phone:702-601-2697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802081610104100000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No104100000XBehavioral Health & Social Service ProvidersSocial Worker