Provider Demographics
NPI:1992184410
Name:GREEN, GRADIE
Entity Type:Individual
Prefix:
First Name:GRADIE
Middle Name:
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 1:6701 SW BAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9026
Mailing Address - Country:US
Mailing Address - Phone:580-704-5521
Mailing Address - Fax:580-585-4619
Practice Address - Street 1:6701 SW BAYWOOD DR
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-9026
Practice Address - Country:US
Practice Address - Phone:580-704-5521
Practice Address - Fax:580-585-4619
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor