Provider Demographics
NPI:1811687726
Name:GREEN, TRENTON LAMAR (MA)
Entity type:Individual
Prefix:
First Name:TRENTON
Middle Name:LAMAR
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:803 BRISCO AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5161
Mailing Address - Country:US
Mailing Address - Phone:318-283-3299
Mailing Address - Fax:318-283-3298
Practice Address - Street 1:803 BRISCO AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5161
Practice Address - Country:US
Practice Address - Phone:318-283-3299
Practice Address - Fax:318-283-3298
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LAPLC9729101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator