Provider Demographics
NPI:1285022715
Name:GREEN, ROXANNE (LCDC)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 HIGHWAY 59 LOOP S
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-9012
Mailing Address - Country:US
Mailing Address - Phone:281-809-4142
Mailing Address - Fax:
Practice Address - Street 1:309 HIGHWAY 59 LOOP S
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-9012
Practice Address - Country:US
Practice Address - Phone:281-809-4142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14401101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)