Provider Demographics
NPI:1518542299
Name:GREEN, MELINDA GAIL (LCDC- I, LPC STUDENT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:GAIL
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCDC- I, LPC STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8244 COTTONWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TERRELL
Mailing Address - State:TX
Mailing Address - Zip Code:75160-7401
Mailing Address - Country:US
Mailing Address - Phone:254-423-9378
Mailing Address - Fax:
Practice Address - Street 1:1837 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-4401
Practice Address - Country:US
Practice Address - Phone:903-910-2294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-14
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)