Provider Demographics
NPI:1306205638
Name:GREEN, EDDIE JR
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:GREEN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6305 ELYSIAN FIELDS AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70122-4284
Mailing Address - Country:US
Mailing Address - Phone:504-324-7332
Mailing Address - Fax:
Practice Address - Street 1:6305 ELYSIAN FIELDS AVE STE 405
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70122-4284
Practice Address - Country:US
Practice Address - Phone:504-324-7332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health