Provider Demographics
NPI:1336331974
Name:GREEN, TRAVELL (MHPP)
Entity Type:Individual
Prefix:
First Name:TRAVELL
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3352 N FUTRALL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4057
Mailing Address - Country:US
Mailing Address - Phone:479-521-5868
Mailing Address - Fax:
Practice Address - Street 1:1484 W 1ST ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AR
Practice Address - Zip Code:71857-3339
Practice Address - Country:US
Practice Address - Phone:870-887-1078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-17
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator