Provider Demographics
NPI:1669697504
Name:GREEN, RONNIE (PSY)
Entity type:Individual
Prefix:
First Name:RONNIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 S POTOMAC ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80012-4524
Mailing Address - Country:US
Mailing Address - Phone:303-745-1281
Mailing Address - Fax:303-671-2854
Practice Address - Street 1:1290 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-4524
Practice Address - Country:US
Practice Address - Phone:303-745-1281
Practice Address - Fax:303-671-2854
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSY-908101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7009087Medicaid