Provider Demographics
NPI:1134339245
Name:GREEN, MARY J, PHILLIPS (PHD,LMHC,LMFT, LCPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J, PHILLIPS
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD,LMHC,LMFT, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10324 CANYON RD E
Mailing Address - Street 2:SUITE 208
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-1013
Mailing Address - Country:US
Mailing Address - Phone:253-267-1760
Mailing Address - Fax:253-503-1628
Practice Address - Street 1:10324 CANYON RD E
Practice Address - Street 2:SUITE 208
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-1013
Practice Address - Country:US
Practice Address - Phone:253-267-1760
Practice Address - Fax:253-503-1628
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00009327101YM0800X
IDLCPC-399101YM0800X
IDLMFT-35106H00000X
WALF-00002624106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health