Provider Demographics
NPI:1891051330
Name:GREEN, MALITA ELICE (BA)
Entity Type:Individual
Prefix:MRS
First Name:MALITA
Middle Name:ELICE
Last Name:GREEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-9710
Mailing Address - Country:US
Mailing Address - Phone:405-808-5875
Mailing Address - Fax:
Practice Address - Street 1:102 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-9710
Practice Address - Country:US
Practice Address - Phone:405-808-5875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health