Provider Demographics
NPI:1427216217
Name:GREEN, DEANDRE LISA (MED)
Entity Type:Individual
Prefix:MS
First Name:DEANDRE
Middle Name:LISA
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8485 BAROSSA CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-9158
Mailing Address - Country:US
Mailing Address - Phone:702-736-8100
Mailing Address - Fax:702-736-7881
Practice Address - Street 1:5615 S PECOS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-1961
Practice Address - Country:US
Practice Address - Phone:702-736-8100
Practice Address - Fax:702-736-7881
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor