Provider Demographics
NPI:1619336351
Name:GREEN, BRIAN L (LMHC, LPC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17586 SW DODSON DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8185
Mailing Address - Country:US
Mailing Address - Phone:608-239-5120
Mailing Address - Fax:360-252-8699
Practice Address - Street 1:17586 SW DODSON DR
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-8185
Practice Address - Country:US
Practice Address - Phone:608-239-5120
Practice Address - Fax:360-252-8699
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8627-125101YM0800X
WALH60807062101YM0800X
ORC7806101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health