Provider Demographics
NPI:1588196588
Name:GREEN, KATESHIA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATESHIA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7118
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71306-0118
Mailing Address - Country:US
Mailing Address - Phone:318-484-6850
Mailing Address - Fax:318-484-6506
Practice Address - Street 1:242 W SHAMROCK AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6439
Practice Address - Country:US
Practice Address - Phone:318-484-6850
Practice Address - Fax:318-484-6506
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA109911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical