Provider Demographics
NPI:1376069534
Name:GREEN, LATISHA (BCBA)
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8929 SIERRA TRL
Mailing Address - Street 2:
Mailing Address - City:CROSSROADS
Mailing Address - State:TX
Mailing Address - Zip Code:76227-2266
Mailing Address - Country:US
Mailing Address - Phone:940-600-7202
Mailing Address - Fax:
Practice Address - Street 1:8929 SIERRA TRL
Practice Address - Street 2:
Practice Address - City:CROSSROADS
Practice Address - State:TX
Practice Address - Zip Code:76227-2266
Practice Address - Country:US
Practice Address - Phone:940-600-7202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-17-26129103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst