Provider Demographics
NPI:1770528770
Name:GREEN, MARTHA G (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:G
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 S COLLEGE RD
Mailing Address - Street 2:STE A
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503
Mailing Address - Country:US
Mailing Address - Phone:337-232-9113
Mailing Address - Fax:337-232-0022
Practice Address - Street 1:1105 S COLLEGE RD
Practice Address - Street 2:STE A
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503
Practice Address - Country:US
Practice Address - Phone:337-232-9113
Practice Address - Fax:337-232-0022
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LASCG20OtherGROUP MEDICARE #
LASCG20OtherGROUP MEDICARE #