Provider Demographics
NPI:1063124659
Name:GREEN-TAYLOR, DEMETRIA
Entity type:Individual
Prefix:
First Name:DEMETRIA
Middle Name:
Last Name:GREEN-TAYLOR
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 1:2015 FAIRFIELD AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2066
Mailing Address - Country:US
Mailing Address - Phone:318-675-0406
Mailing Address - Fax:318-675-0408
Practice Address - Street 1:2015 FAIRFIELD AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2066
Practice Address - Country:US
Practice Address - Phone:318-675-0406
Practice Address - Fax:318-675-0408
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator