Provider Demographics
NPI:1619281979
Name:GREEN, LARRY (LMFT)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:18015 SW 95TH AVE
Mailing Address - Street 2:
Mailing Address - City:ARCHER
Mailing Address - State:FL
Mailing Address - Zip Code:32618-3407
Mailing Address - Country:US
Mailing Address - Phone:352-448-9120
Mailing Address - Fax:
Practice Address - Street 1:1001 NE 16TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-2511
Practice Address - Country:US
Practice Address - Phone:352-448-9120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2733106H00000X
NC1419106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMT2733OtherLICENSE