Provider Demographics
NPI:1235504465
Name:GREEN, BRAIDEN NICOLE
Entity Type:Individual
Prefix:
First Name:BRAIDEN
Middle Name:NICOLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRAIDEN
Other - Middle Name:NICOLE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1605 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-4022
Mailing Address - Country:US
Mailing Address - Phone:405-765-6188
Mailing Address - Fax:
Practice Address - Street 1:9212 N KELLEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73131-2419
Practice Address - Country:US
Practice Address - Phone:405-242-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-14
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor