Provider Demographics
NPI:1679500318
Name:GREEN, VIRGINIA K (LCSW)
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:K
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 1:7272 WURZBACH RD
Mailing Address - Street 2:SUITE 601
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4801
Mailing Address - Country:US
Mailing Address - Phone:210-615-3405
Mailing Address - Fax:210-615-2279
Practice Address - Street 1:1112 SAN PEDRO DR NE
Practice Address - Street 2:SUITE 222
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6724
Practice Address - Country:US
Practice Address - Phone:505-254-3505
Practice Address - Fax:210-615-2279
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-42361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM16088531Medicaid