Healthcare Provider Details

I. General information

NPI: 1689804320
Provider Name (Legal Business Name): RANDY DALE GREEN MS, LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W 3RD ST
FORDYCE AR
71742-3014
US

IV. Provider business mailing address

1101 W 3RD ST
FORDYCE AR
71742-3014
US

V. Phone/Fax

Practice location:
  • Phone: 870-352-5122
  • Fax: 870-352-5127
Mailing address:
  • Phone: 870-352-5122
  • Fax: 870-352-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP1109064
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: