Provider Demographics
NPI:1205458817
Name:GREEN, BECKY I
Entity type:Individual
Prefix:MRS
First Name:BECKY
Middle Name:I
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 1:633 E BIRCHFIELD LN APT 7D
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2239
Mailing Address - Country:US
Mailing Address - Phone:406-217-5357
Mailing Address - Fax:
Practice Address - Street 1:633 E BIRCHFIELD LN APT 7D
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-2239
Practice Address - Country:US
Practice Address - Phone:406-217-5357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician