Provider Demographics
NPI:1760104756
Name:GREEN, MADISON BAILEE (LPC)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:BAILEE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 W CADDO ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OK
Mailing Address - Zip Code:74020-4201
Mailing Address - Country:US
Mailing Address - Phone:580-747-8812
Mailing Address - Fax:
Practice Address - Street 1:907 W CADDO ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OK
Practice Address - Zip Code:74020-4201
Practice Address - Country:US
Practice Address - Phone:539-325-0739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPCCANDIDATE10997101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional