Provider Demographics
NPI:1033589569
Name:GREEN, MARK STEPHEN (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 FAIRMOUNT ST
Mailing Address - Street 2:BOX 91
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67260-0091
Mailing Address - Country:US
Mailing Address - Phone:316-978-6102
Mailing Address - Fax:316-978-3216
Practice Address - Street 1:9415 E HARRY ST
Practice Address - Street 2:SUITE 703
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5089
Practice Address - Country:US
Practice Address - Phone:316-978-6102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2354103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist