Provider Demographics
NPI:1447876347
Name:GREEN, LEA MARIA THERESE (MHC-LP)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:MARIA THERESE
Last Name:GREEN
Suffix:
Gender:F
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-3559
Mailing Address - Country:US
Mailing Address - Phone:516-491-9962
Mailing Address - Fax:
Practice Address - Street 1:98 PARK AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-1709
Practice Address - Country:US
Practice Address - Phone:802-532-5642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-17
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP14079101YM0800X
101YM0800X
NYP14097101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health