Provider Demographics
NPI:1740382704
Name:GREEN, LARRY (LP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 E LUVERNE ST
Mailing Address - Street 2:PO BOX 686
Mailing Address - City:LUVERNE
Mailing Address - State:MN
Mailing Address - Zip Code:56156-1610
Mailing Address - Country:US
Mailing Address - Phone:507-283-9511
Mailing Address - Fax:507-283-9514
Practice Address - Street 1:216 E LUVERNE ST
Practice Address - Street 2:
Practice Address - City:LUVERNE
Practice Address - State:MN
Practice Address - Zip Code:56156-1610
Practice Address - Country:US
Practice Address - Phone:507-283-9511
Practice Address - Fax:507-283-9514
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1054103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical