Provider Demographics
NPI:1508951856
Name:GREEN, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:SHARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2424 32ND AVE S
Mailing Address - Street 2:STE 202
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6545
Mailing Address - Country:US
Mailing Address - Phone:701-746-6336
Mailing Address - Fax:701-772-1030
Practice Address - Street 1:2424 32ND AVE S
Practice Address - Street 2:STE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6545
Practice Address - Country:US
Practice Address - Phone:701-746-6336
Practice Address - Fax:701-772-1030
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND270103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18288Medicaid
ND24743OtherBLUECROSSBLUESHIELD OF ND
ND1451969Medicaid
MN309K9GROtherBLUECROSSBLUESHIELD OF MN
ND61-66614OtherUBH
ND498806OtherVALUE OPTIONS
ND18288Medicaid