Provider Demographics
NPI:1265628853
Name:GREEN, MARY JANE (LPC CANDIDATE)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HEAVENER
Mailing Address - State:OK
Mailing Address - Zip Code:74937-3419
Mailing Address - Country:US
Mailing Address - Phone:918-653-7718
Mailing Address - Fax:918-653-7279
Practice Address - Street 1:511 E 2ND ST
Practice Address - Street 2:
Practice Address - City:HEAVENER
Practice Address - State:OK
Practice Address - Zip Code:74937-3419
Practice Address - Country:US
Practice Address - Phone:918-653-7718
Practice Address - Fax:918-653-7279
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100706960FMedicaid