Provider Demographics
NPI:1740720416
Name:GREEN, CHEVAUGHN RONEE
Entity type:Individual
Prefix:
First Name:CHEVAUGHN
Middle Name:RONEE
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 1:428 ALPINE ST
Mailing Address - Street 2:#109
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-7718
Mailing Address - Country:US
Mailing Address - Phone:909-362-4793
Mailing Address - Fax:
Practice Address - Street 1:428 ALPINE ST
Practice Address - Street 2:#109
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-7718
Practice Address - Country:US
Practice Address - Phone:909-362-4793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician