Basic Information
| Provider Information | |||||||||
| NPI: | 1124588744 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | MONICA | ||||||||
| MiddleName: | LELA | ||||||||
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| Credential: | CO60928239 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 W BOONE AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093257232 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 910 W BOONE AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093257232 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2019 | ||||||||
| LastUpdateDate: | 03/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CO60928239 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 05 | WA | MEDICAID |