Provider Demographics
NPI:1982006623
Name:GREEN, BRENDA JOYCE
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:JOYCE
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:BRENDA
Other - Middle Name:JOYCE
Other - Last Name:GREEN-SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CASE MANAGER II
Mailing Address - Street 1:1123 E.1ST STREET
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447
Mailing Address - Country:US
Mailing Address - Phone:918-304-7071
Mailing Address - Fax:
Practice Address - Street 1:1123 E 1ST ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-3725
Practice Address - Country:US
Practice Address - Phone:918-304-7071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1649519109Medicaid