Provider Demographics
NPI:1437774221
Name:THE GREEN ROOM THERAPY, LLC
Entity Type:Organization
Organization Name:THE GREEN ROOM THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SANGEETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAIR
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:808-234-4435
Mailing Address - Street 1:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:KEALAKEKUA
Mailing Address - State:HI
Mailing Address - Zip Code:96750-0863
Mailing Address - Country:US
Mailing Address - Phone:808-234-4435
Mailing Address - Fax:
Practice Address - Street 1:78-6831 ALII DRIVE
Practice Address - Street 2:SPACE E234, UNIT # 211
Practice Address - City:KAILUA-KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-9674
Practice Address - Country:US
Practice Address - Phone:808-234-4435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty