Provider Demographics
NPI:1104581065
Name:GREEN, MARY GRAYSON
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRAYSON
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 1:1462 HOMESTEAD LN
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75007-2991
Mailing Address - Country:US
Mailing Address - Phone:614-561-3246
Mailing Address - Fax:
Practice Address - Street 1:4500 HILLCREST RD STE 150
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-5420
Practice Address - Country:US
Practice Address - Phone:469-535-3844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician