Provider Demographics
NPI:1326758509
Name:GREEN, PAMELA (LAC)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 S KYRENE RD STE 227
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-2177
Mailing Address - Country:US
Mailing Address - Phone:602-919-5685
Mailing Address - Fax:
Practice Address - Street 1:8400 S KYRENE RD STE 227
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2177
Practice Address - Country:US
Practice Address - Phone:602-919-5685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-16177101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health