Provider Demographics
NPI:1902001951
Name:GREEN, CHERYL A (MED, LSW, LPC)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:MED, LSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1046
Mailing Address - Country:US
Mailing Address - Phone:662-627-7267
Mailing Address - Fax:662-627-5240
Practice Address - Street 1:421 1ST ST
Practice Address - Street 2:
Practice Address - City:MARKS
Practice Address - State:MS
Practice Address - Zip Code:38646-1302
Practice Address - Country:US
Practice Address - Phone:662-326-4445
Practice Address - Fax:662-627-5240
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0656101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health