Provider Demographics
NPI:1376602110
Name:GREEN, DARYL (LPC LMFT NCC)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LPC LMFT NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76503-0416
Mailing Address - Country:US
Mailing Address - Phone:254-774-8806
Mailing Address - Fax:254-774-9672
Practice Address - Street 1:1805 FLORENCE RD
Practice Address - Street 2:SUITE 10
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76541-8523
Practice Address - Country:US
Practice Address - Phone:254-526-5389
Practice Address - Fax:254-526-4853
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13560101YP2500X
TX4672106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX13560OtherLPC LICENSE NUMBER
TX4672OtherLMFT LICENSE
TX027164502Medicaid