Provider Demographics
NPI:1922770015
Name:GREEN, DAMARLO
Entity Type:Individual
Prefix:
First Name:DAMARLO
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 DESERT SENNA AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-4717
Mailing Address - Country:US
Mailing Address - Phone:702-373-0545
Mailing Address - Fax:
Practice Address - Street 1:524 DESERT SENNA AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-4717
Practice Address - Country:US
Practice Address - Phone:702-373-0545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker