Healthcare Provider Details

I. General information

NPI: 1992914162
Provider Name (Legal Business Name): DANA MARIE GREEN LPC, NCGC-II
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANA BOLDT GREEN LPC

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717B HIGHWAY 70 E
KINGSTON OK
73439-8253
US

IV. Provider business mailing address

PO BOX 1800
KINGSTON OK
73439-1800
US

V. Phone/Fax

Practice location:
  • Phone: 580-565-2252
  • Fax: 580-564-7187
Mailing address:
  • Phone: 580-565-2252
  • Fax: 580-564-7187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2011
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLPC2011
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: