Provider Demographics
NPI:1518373513
Name:DANA BOLDT GREEN, M.ED., LPC, NCGC-2, PC
Entity Type:Organization
Organization Name:DANA BOLDT GREEN, M.ED., LPC, NCGC-2, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:5850-565-2252
Mailing Address - Street 1:PO BOX 1800
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-1800
Mailing Address - Country:US
Mailing Address - Phone:580-565-2252
Mailing Address - Fax:
Practice Address - Street 1:8800 BIRCH ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439
Practice Address - Country:US
Practice Address - Phone:580-565-2252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2011251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health