Provider Demographics
NPI:1578612123
Name:GREEN, RICKY NEAL (LICSW)
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:NEAL
Last Name:GREEN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 KEY ST STE 108
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-5251
Mailing Address - Country:US
Mailing Address - Phone:360-647-1176
Mailing Address - Fax:360-734-2121
Practice Address - Street 1:1116 KEY ST STE 108
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-5251
Practice Address - Country:US
Practice Address - Phone:360-647-1176
Practice Address - Fax:360-734-2121
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000055391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4462GROtherHMO PIN
WAAB26143Medicare PIN