Provider Demographics
NPI:1326416181
Name:GREEN, STACY KATRINA (160010197)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:KATRINA
Last Name:GREEN
Suffix:
Gender:F
Credentials:160010197
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:KATRINA
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:1314015
Mailing Address - Street 1:900 CHURCH ST
Mailing Address - Street 2:D2
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-1668
Mailing Address - Country:US
Mailing Address - Phone:864-387-7998
Mailing Address - Fax:
Practice Address - Street 1:900 CHURCH ST
Practice Address - Street 2:D2
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-1668
Practice Address - Country:US
Practice Address - Phone:864-387-7998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1314015106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist