Provider Demographics
NPI:1891476776
Name:GREEN, TYREE JONTA (LCSWA)
Entity Type:Individual
Prefix:
First Name:TYREE
Middle Name:JONTA
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 HAMPTON LN
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27596-8743
Mailing Address - Country:US
Mailing Address - Phone:704-267-1885
Mailing Address - Fax:
Practice Address - Street 1:943 W ANDREWS AVE STE N
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2562
Practice Address - Country:US
Practice Address - Phone:252-598-2462
Practice Address - Fax:252-598-0956
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0193891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical