Provider Demographics
NPI:1659890135
Name:GREEN, MARILYN EVANS (LPC, CAC III, MA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:EVANS
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC, CAC III, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4856 INNOVATION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-5540
Mailing Address - Country:US
Mailing Address - Phone:970-494-4200
Mailing Address - Fax:
Practice Address - Street 1:4856 INNOVATION DR STE B
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-5540
Practice Address - Country:US
Practice Address - Phone:970-494-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC.0002025101YA0400X
COLPC.0000425101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)