Provider Demographics
NPI:1801132816
Name:GREEN, ANGELIQUE EMIRITHA (LCDC)
Entity type:Individual
Prefix:MS
First Name:ANGELIQUE
Middle Name:EMIRITHA
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2527 CHESTNUT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-3031
Mailing Address - Country:US
Mailing Address - Phone:281-348-9008
Mailing Address - Fax:832-519-1664
Practice Address - Street 1:2527 CHESTNUT RIDGE DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-3031
Practice Address - Country:US
Practice Address - Phone:281-348-9008
Practice Address - Fax:832-519-1664
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10627101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)