Provider Demographics
NPI:1669735957
Name:GREEN, MARY ANN (MA, LPC, RD, LD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MA, LPC, RD, LD
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:WOODWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC, RD, LD
Mailing Address - Street 1:1010 4TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1110
Mailing Address - Country:US
Mailing Address - Phone:615-724-0865
Mailing Address - Fax:615-724-0871
Practice Address - Street 1:1010 4TH AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37219-1110
Practice Address - Country:US
Practice Address - Phone:615-724-0865
Practice Address - Fax:615-724-0871
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006148101YP2500X
GALD002780133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered