Provider Demographics
NPI:1023283074
Name:GREEN, LATASHA RENEA (LCAS LPC CCS)
Entity type:Individual
Prefix:
First Name:LATASHA
Middle Name:RENEA
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCAS LPC CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7281
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27835-7281
Mailing Address - Country:US
Mailing Address - Phone:252-367-7478
Mailing Address - Fax:252-751-0661
Practice Address - Street 1:312 STERLINGWORTH ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-1724
Practice Address - Country:US
Practice Address - Phone:252-794-3834
Practice Address - Fax:252-794-3204
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NC7704101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6112085Medicaid