Healthcare Provider Details

I. General information

NPI: 1255027199
Provider Name (Legal Business Name): CHELSEA RENEE GREEN BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2023
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 SCENIC DR
BLUE RIDGE GA
30513-4453
US

IV. Provider business mailing address

2800 SCENIC DR
BLUE RIDGE GA
30513-4453
US

V. Phone/Fax

Practice location:
  • Phone: 706-889-1124
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-77228
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-233238
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: