Provider Demographics
NPI:1457861106
Name:GREEN, LEMARRICK (MHT)
Entity Type:Individual
Prefix:
First Name:LEMARRICK
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 W REED RD STE A-1
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-6967
Mailing Address - Country:US
Mailing Address - Phone:662-702-5108
Mailing Address - Fax:
Practice Address - Street 1:365 W REED RD STE A-1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-6967
Practice Address - Country:US
Practice Address - Phone:662-702-5108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1396196879Medicaid