Provider Demographics
NPI:1316414485
Name:GREEN, LUCILA STEPHANIE
Entity Type:Individual
Prefix:
First Name:LUCILA
Middle Name:STEPHANIE
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 1:1430 COLLIER ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-2911
Mailing Address - Country:US
Mailing Address - Phone:512-472-4357
Mailing Address - Fax:512-703-1394
Practice Address - Street 1:5015 S IH 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-2713
Practice Address - Country:US
Practice Address - Phone:512-804-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75674101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional