Provider Demographics
NPI:1215394903
Name:GREEN, CHANNIN
Entity Type:Individual
Prefix:
First Name:CHANNIN
Middle Name:
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 1:23445 GAUTHIER ST
Mailing Address - Street 2:
Mailing Address - City:PLAQUEMINE
Mailing Address - State:LA
Mailing Address - Zip Code:70764-2665
Mailing Address - Country:US
Mailing Address - Phone:225-385-9867
Mailing Address - Fax:
Practice Address - Street 1:23445 GAUTHIER ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-2665
Practice Address - Country:US
Practice Address - Phone:225-385-9867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health