Healthcare Provider Details

I. General information

NPI: 1457422123
Provider Name (Legal Business Name): REBECCA ROSE GREEN PROVISIONAL LICENSED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 SO LINCOLN AVE SUITE 1
YORK NE
68467
US

IV. Provider business mailing address

1604 ROAD E
BRADSHAW NE
68319
US

V. Phone/Fax

Practice location:
  • Phone: 402-362-6128
  • Fax: 402-362-7012
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number730
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: