Provider Demographics
NPI:1780008342
Name:GREEN, BRENDEN EUGENE (LPCC, LCPC)
Entity Type:Individual
Prefix:MR
First Name:BRENDEN
Middle Name:EUGENE
Last Name:GREEN
Suffix:
Gender:M
Credentials:LPCC, LCPC
Other - Prefix:MR
Other - First Name:BRENDEN
Other - Middle Name:EUGENE
Other - Last Name:DIX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCC, LCPC
Mailing Address - Street 1:6315 LONE MOOSE CT
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MT
Mailing Address - Zip Code:59833-6005
Mailing Address - Country:US
Mailing Address - Phone:505-977-5376
Mailing Address - Fax:
Practice Address - Street 1:2875 TINA AVE STE 106
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1582
Practice Address - Country:US
Practice Address - Phone:406-552-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0164301101YP2500X
CO0013284101YP2500X
MTBBH-LCPC-LIC-43089101YP2500X
NM0181451101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1780008342Medicaid
MT0686766Medicaid