Provider Demographics
NPI:1477087799
Name:GREEN, VANESSA (EDS)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1724 N BURNSIDE AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-2157
Mailing Address - Country:US
Mailing Address - Phone:225-644-8565
Mailing Address - Fax:225-644-6261
Practice Address - Street 1:1724 N BURNSIDE AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-2157
Practice Address - Country:US
Practice Address - Phone:225-644-8565
Practice Address - Fax:225-644-6261
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health