Provider Demographics
NPI:1689818411
Name:GREEN, MARY SUE (LMFT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:SUE
Other - Last Name:TOBEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:804 COMBS ST
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-4444
Mailing Address - Country:US
Mailing Address - Phone:940-536-3644
Mailing Address - Fax:
Practice Address - Street 1:8150 US HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201-7152
Practice Address - Country:US
Practice Address - Phone:940-536-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000311101YM0800X
TX201547101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health