Basic Information
| Provider Information | |||||||||
| NPI: | 1689804320 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717423014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703525122 | ||||||||
| FaxNumber: | 8703525127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717423014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703525122 | ||||||||
| FaxNumber: | 8703525127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 03/25/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P1109064 | AR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.