Healthcare Provider Details

I. General information

NPI: 1659724631
Provider Name (Legal Business Name): RICHARD ALLEN GREEN PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 4200 WILSON HALL
FORT BENNING GA
31905
US

IV. Provider business mailing address

7487 OBRIEN LOOP
FORT BENNING GA
31905-2761
US

V. Phone/Fax

Practice location:
  • Phone: 706-626-5904
  • Fax:
Mailing address:
  • Phone: 229-942-9870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN246976
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: