Provider Demographics
NPI:1902510787
Name:GREEN, AUTUMN MAREE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MAREE
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 1:618 CLARA BARTON BLVD STE 7
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5731
Mailing Address - Country:US
Mailing Address - Phone:214-385-5445
Mailing Address - Fax:
Practice Address - Street 1:618 CLARA BARTON BLVD STE 7
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5731
Practice Address - Country:US
Practice Address - Phone:214-385-5445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty