Provider Demographics
NPI:1194949545
Name:GREEN, CAMILLE (SW)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 SUNSHINE TER SE
Mailing Address - Street 2:LOWELL ES
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-3906
Mailing Address - Country:US
Mailing Address - Phone:505-764-2011
Mailing Address - Fax:
Practice Address - Street 1:1700 SUNSHINE TER SE
Practice Address - Street 2:LOWELL ES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3906
Practice Address - Country:US
Practice Address - Phone:505-764-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM 57001041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35288230Medicaid