Provider Demographics
NPI:1831411263
Name:GREEN, JOHNNY DUANE
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:DUANE
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:PO BOX 1427
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1427
Mailing Address - Country:US
Mailing Address - Phone:580-277-5423
Mailing Address - Fax:
Practice Address - Street 1:105 PLAZA
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-2248
Practice Address - Country:US
Practice Address - Phone:580-795-7439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor