Provider Demographics
NPI:1124588744
Name:GREEN, MONICA LELA (CO60928239)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:LELA
Last Name:GREEN
Suffix:
Gender:F
Credentials:CO60928239
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W BOONE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2525
Mailing Address - Country:US
Mailing Address - Phone:509-325-7232
Mailing Address - Fax:
Practice Address - Street 1:910 W BOONE AVE STE 201
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-2525
Practice Address - Country:US
Practice Address - Phone:509-325-7232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60928239101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA101YA0400XMedicaid