MEDICARE: MIA GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		CO

General Provider Information

NPI Number	:	1689537698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA GREEN

Provider Business Mailing Address
First Line	:	7125 YAMPA RIVER HTS
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-1570
Country	:	US
Telephone Number	:	719-930-5253
Fax Number	:

Provider Business Practice Location Address
First Line	:	6436 S US HIGHWAY 85-87
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-1005
Country	:	US
Telephone Number	:	719-822-0460
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	12/05/2025

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Directions to “ MIA GREEN ” Practice Location

Language	Start Address	Practice Location

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