Provider Demographics
NPI:1487993937
Name:GREEN, SHEILA C (LPC)
Entity type:Individual
Prefix:MS
First Name:SHEILA
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 GEMINI DR
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-3468
Mailing Address - Country:US
Mailing Address - Phone:318-282-2395
Mailing Address - Fax:
Practice Address - Street 1:803 BRISCO AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5161
Practice Address - Country:US
Practice Address - Phone:318-974-6035
Practice Address - Fax:318-515-0019
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA213106H00000X
LA2854101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3941503Medicaid