Provider Demographics
NPI:1558686162
Name:GREEN, STACY ROBIN (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ROBIN
Last Name:GREEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3985 WONDERLAND HILL AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-1038
Mailing Address - Country:US
Mailing Address - Phone:303-717-2521
Mailing Address - Fax:
Practice Address - Street 1:3985 WONDERLAND HILL AVE STE 107
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-1038
Practice Address - Country:US
Practice Address - Phone:303-717-2521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CO50364208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No101Y00000XBehavioral Health & Social Service ProvidersCounselor