Provider Demographics
NPI:1295180065
Name:GREEN, TANEA (M ED, PLPC)
Entity Type:Individual
Prefix:
First Name:TANEA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:M ED, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 S SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:HOLTS SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:65043-2048
Mailing Address - Country:US
Mailing Address - Phone:573-645-7849
Mailing Address - Fax:
Practice Address - Street 1:718 W MCCARTY ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-1544
Practice Address - Country:US
Practice Address - Phone:573-645-7849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015044363101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional