Basic Information
| Provider Information | |||||||||
| NPI: | 1669697504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | RONNIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 S POTOMAC ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800124524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037451281 | ||||||||
| FaxNumber: | 3036712854 | ||||||||
| Practice Location | |||||||||
| Address1: | 1290 S POTOMAC ST | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800124524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037451281 | ||||||||
| FaxNumber: | 3036712854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PSY-908 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7009087 | 05 | CO | MEDICAID |