Provider Demographics
NPI:1063282374
Name:GREEN, TRALACIA A
Entity type:Individual
Prefix:
First Name:TRALACIA
Middle Name:A
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 1:142 ASH ST
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-6852
Mailing Address - Country:US
Mailing Address - Phone:504-919-2329
Mailing Address - Fax:
Practice Address - Street 1:142 ASH ST
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-6852
Practice Address - Country:US
Practice Address - Phone:504-919-2329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
LALA9985225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist