Provider Demographics
NPI:1154604791
Name:GREEN, TERRY A (MS, LMFTA)
Entity type:Individual
Prefix:MRS
First Name:TERRY
Middle Name:A
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98020-3096
Mailing Address - Country:US
Mailing Address - Phone:206-321-4850
Mailing Address - Fax:
Practice Address - Street 1:611 MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98020-3096
Practice Address - Country:US
Practice Address - Phone:206-321-4850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMG60292466106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program