Provider Demographics
NPI:1821413758
Name:GREEN, AMY MARIE
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28425 N BLACK CANYON HWY
Mailing Address - Street 2:UNIT 2088
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-7601
Mailing Address - Country:US
Mailing Address - Phone:480-404-0716
Mailing Address - Fax:
Practice Address - Street 1:212 I ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4213
Practice Address - Country:US
Practice Address - Phone:530-601-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-01
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101Y00000X
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXXXXXOtherUNCERTAIN