Provider Demographics
NPI:1689632804
Name:GREEN, TANYA LAURETTE (MSW)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:LAURETTE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2048
Mailing Address - Country:US
Mailing Address - Phone:260-490-8110
Mailing Address - Fax:260-490-7707
Practice Address - Street 1:310 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2048
Practice Address - Country:US
Practice Address - Phone:260-490-8110
Practice Address - Fax:260-490-7707
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005094A1041C0700X
OK15311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical