Provider Demographics
NPI:1902597057
Name:GREEN, LAKETA
Entity Type:Individual
Prefix:
First Name:LAKETA
Middle Name:
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 1:7320 S RAINBOW BLVD # 102-192
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-0406
Mailing Address - Country:US
Mailing Address - Phone:702-625-1079
Mailing Address - Fax:
Practice Address - Street 1:7320 S RAINBOW BLVD # 102-192
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-0406
Practice Address - Country:US
Practice Address - Phone:702-625-1079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health