Provider Demographics
NPI:1245507649
Name:GREEN, ANDRE'
Entity type:Individual
Prefix:MR
First Name:ANDRE'
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 1:2980 S RAINBOW BLVD
Mailing Address - Street 2:SUITE 200 E
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6531
Mailing Address - Country:US
Mailing Address - Phone:702-219-8788
Mailing Address - Fax:702-889-4406
Practice Address - Street 1:2980 S RAINBOW BLVD
Practice Address - Street 2:SUITE 200 E
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6531
Practice Address - Country:US
Practice Address - Phone:702-219-8788
Practice Address - Fax:702-889-4406
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1902075005Medicaid