Provider Demographics
NPI:1710293303
Name:GREEN, TYRA NICOLE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:TYRA
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 WINDSOR MILL RD
Mailing Address - Street 2:
Mailing Address - City:GWYNN OAK
Mailing Address - State:MD
Mailing Address - Zip Code:21207-5924
Mailing Address - Country:US
Mailing Address - Phone:240-274-2951
Mailing Address - Fax:301-856-9589
Practice Address - Street 1:5502 WINDSOR MILL RD
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-5924
Practice Address - Country:US
Practice Address - Phone:240-274-2951
Practice Address - Fax:301-856-9589
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-20
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2671101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional