Provider Demographics
NPI:1447324033
Name:GREEN, SUSAN BLAKE
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BLAKE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:BLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT, LPC
Mailing Address - Street 1:2500 LINCOLN DR
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79601-2023
Mailing Address - Country:US
Mailing Address - Phone:325-676-4030
Mailing Address - Fax:325-676-2016
Practice Address - Street 1:2500 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2023
Practice Address - Country:US
Practice Address - Phone:325-676-4030
Practice Address - Fax:325-676-2016
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9853101YP2500X
TX623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3648 LCOtherBLUE CROSS BLUE SHIELD #