Provider Demographics
NPI:1790462786
Name:GREEN, CONNIE LAVERNE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:LAVERNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S MOPAC EXPY STE C300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-7077
Mailing Address - Country:US
Mailing Address - Phone:512-920-1030
Mailing Address - Fax:512-256-1983
Practice Address - Street 1:230 S NOLEN DR BLDG 3
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-8078
Practice Address - Country:US
Practice Address - Phone:817-402-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5920103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst