Healthcare Provider Details

I. General information

NPI: 1558686162
Provider Name (Legal Business Name): STACY ROBIN GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 S BROADWAY ST STE 100
BOULDER CO
80305-5932
US

IV. Provider business mailing address

825 S BROADWAY ST STE 100
BOULDER CO
80305-5932
US

V. Phone/Fax

Practice location:
  • Phone: 303-717-2521
  • Fax:
Mailing address:
  • Phone: 303-717-2521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDR.0050364
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License NumberDR.0050364
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: