Provider Demographics
NPI:1336723725
Name:GREEN, MOIRA ELAN
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:ELAN
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 1:2915 CHIPPEWA TRL NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52411-7735
Mailing Address - Country:US
Mailing Address - Phone:319-550-2129
Mailing Address - Fax:
Practice Address - Street 1:1555 SE DELAWARE AVE STE O
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-4011
Practice Address - Country:US
Practice Address - Phone:515-261-2401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician