Provider Demographics
NPI:1215536644
Name:GREEN, LAURA VANESSA I
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:VANESSA
Last Name:GREEN
Suffix:I
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 1:7605 BEECHLAKE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-1603
Mailing Address - Country:US
Mailing Address - Phone:614-975-1352
Mailing Address - Fax:
Practice Address - Street 1:3042 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3653
Practice Address - Country:US
Practice Address - Phone:614-487-7805
Practice Address - Fax:614-487-7809
Is Sole Proprietor?:No
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician