Provider Demographics
NPI:1700409026
Name:GREEN, EARL MARK (MA LPC, NCC)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:MARK
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 COUNTRY CREEK DR APT 1044
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75236-1220
Mailing Address - Country:US
Mailing Address - Phone:214-636-8956
Mailing Address - Fax:
Practice Address - Street 1:4621 COUNTRY CREEK DR APT 1044
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75236-1220
Practice Address - Country:US
Practice Address - Phone:214-636-8956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13051101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional