Provider Demographics
NPI:1407981772
Name:GREEN, AMY LEIGH (MFT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LEIGH
Last Name:GREEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7110 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-4828
Mailing Address - Country:US
Mailing Address - Phone:360-946-8936
Mailing Address - Fax:
Practice Address - Street 1:7110 S 13TH ST
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-4828
Practice Address - Country:US
Practice Address - Phone:360-946-8936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49114106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist