Provider Demographics
NPI:1497994446
Name:GREEN, REBECCA ANN (CSAC, ICS)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 HARDING STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-5286
Mailing Address - Country:US
Mailing Address - Phone:715-258-6287
Mailing Address - Fax:920-734-2824
Practice Address - Street 1:811 HARDING ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2012
Practice Address - Country:US
Practice Address - Phone:715-258-6287
Practice Address - Fax:920-734-2824
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2037-132101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)