Provider Demographics
NPI:1114167731
Name:GREEN, GARY LANE (MS, LPC, LMFT)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:LANE
Last Name:GREEN
Suffix:
Gender:M
Credentials:MS, LPC, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 793
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-0793
Mailing Address - Country:US
Mailing Address - Phone:479-936-5944
Mailing Address - Fax:
Practice Address - Street 1:1232 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4246
Practice Address - Country:US
Practice Address - Phone:479-936-5944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-21
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP1205057101YP2500X
ARM1205005106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
12387051OtherCAQH