Provider Demographics
NPI:1124643069
Name:GREEN, ZANDRAL KEWAN
Entity type:Individual
Prefix:
First Name:ZANDRAL
Middle Name:KEWAN
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 1:4222 COMMONS CIR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5858
Mailing Address - Country:US
Mailing Address - Phone:601-702-9411
Mailing Address - Fax:
Practice Address - Street 1:3442 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5331
Practice Address - Country:US
Practice Address - Phone:601-634-0181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018215Medicaid