Provider Demographics
NPI:1891222147
Name:GREEN, ESTELLE
Entity Type:Individual
Prefix:
First Name:ESTELLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 S CHERRY ST
Mailing Address - Street 2:LOT 19
Mailing Address - City:GRAMERCY
Mailing Address - State:LA
Mailing Address - Zip Code:70052
Mailing Address - Country:US
Mailing Address - Phone:225-249-9875
Mailing Address - Fax:
Practice Address - Street 1:1500 LAFAYETTE ST
Practice Address - Street 2:SUITE 140
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70053-5732
Practice Address - Country:US
Practice Address - Phone:225-249-9875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA006819345101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health