Provider Demographics
NPI:1093226706
Name:GREEN, CHARLES LEVON (MA, CAC III)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEVON
Last Name:GREEN
Suffix:
Gender:M
Credentials:MA, CAC III
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:803 W 4TH STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003
Mailing Address - Country:US
Mailing Address - Phone:719-225-8639
Mailing Address - Fax:719-924-8299
Practice Address - Street 1:803 W 4TH STREET
Practice Address - Street 2:SUITE D
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003
Practice Address - Country:US
Practice Address - Phone:719-225-8639
Practice Address - Fax:719-924-8299
Is Sole Proprietor?:No
Enumeration Date:2017-10-20
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0001924101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)