Provider Demographics
NPI:1043951429
Name:GREEN, BEATRICE JORDANNA (RBT)
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:JORDANNA
Last Name:GREEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4014
Mailing Address - Country:US
Mailing Address - Phone:337-239-3334
Mailing Address - Fax:337-239-3336
Practice Address - Street 1:112 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4014
Practice Address - Country:US
Practice Address - Phone:337-239-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAR-10907106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician