Provider Demographics
NPI:1326331372
Name:GREEN, BRANDIANNE
Entity Type:Individual
Prefix:
First Name:BRANDIANNE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73703-1345
Mailing Address - Country:US
Mailing Address - Phone:580-748-1129
Mailing Address - Fax:
Practice Address - Street 1:121 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-4027
Practice Address - Country:US
Practice Address - Phone:580-234-8865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst