Provider Demographics
NPI:1336294271
Name:GREEN, TONIA TALISE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:TONIA
Middle Name:TALISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10043 COBURG LANDS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63137-1902
Mailing Address - Country:US
Mailing Address - Phone:314-869-9314
Mailing Address - Fax:
Practice Address - Street 1:10043 COBURG LANDS DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63137-1902
Practice Address - Country:US
Practice Address - Phone:314-869-9314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001659511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495849507Medicaid
MO495849549Medicaid
MO495849531Medicaid
MO495849515Medicaid