Provider Demographics
NPI:1467658658
Name:GREEN, TERI (LCSW)
Entity type:Individual
Prefix:MS
First Name:TERI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4220 N 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5101
Mailing Address - Country:US
Mailing Address - Phone:602-279-7655
Mailing Address - Fax:602-241-5756
Practice Address - Street 1:5701 W TALAVI BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1886
Practice Address - Country:US
Practice Address - Phone:623-486-8202
Practice Address - Fax:623-486-2739
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-12722101YM0800X
AZLMSW-11867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW-12722OtherSTATE OF ARIZONA BOARD OF BEHAVIORAL HEALTH EXAMINERS
AZLMSW-11867OtherBOARD OF BEHAVIORAL HEALTH EXAMINERS