Provider Demographics
NPI:1346665288
Name:JOHNNY D GREEN MSHR, LPC,PC
Entity Type:Organization
Organization Name:JOHNNY D GREEN MSHR, LPC,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSHR, LPC
Authorized Official - Phone:580-277-5423
Mailing Address - Street 1:PO BOX 1427
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1427
Mailing Address - Country:US
Mailing Address - Phone:580-277-5423
Mailing Address - Fax:580-657-2441
Practice Address - Street 1:597 COLT LN
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-9138
Practice Address - Country:US
Practice Address - Phone:580-277-5423
Practice Address - Fax:580-657-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-01
Last Update Date:2014-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4694251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health