Provider Demographics
NPI:1750875530
Name:GREEN, ANGELENE (QMHA, CPRP)
Entity type:Individual
Prefix:MS
First Name:ANGELENE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:QMHA, CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14600 NW CORNELL RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-5442
Mailing Address - Country:US
Mailing Address - Phone:503-645-3581
Mailing Address - Fax:503-690-9605
Practice Address - Street 1:14600 NW CORNELL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229
Practice Address - Country:US
Practice Address - Phone:503-645-3581
Practice Address - Fax:503-690-9605
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X, 175T00000X
OR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist