MEDICARE: NICOLE GREEN LLC

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	101YP2500X	Professional Counselor	0162171	NM

General Provider Information

NPI Number	:	1730506189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICOLE GREEN LLC

Provider Business Mailing Address
First Line	:	1740 GRANDE BLVD SE STE D-7
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1799
Country	:	US
Telephone Number	:	505-750-1069
Fax Number	:	844-714-2499

Provider Business Practice Location Address
First Line	:	1740 GRANDE BLVD SE STE D-7
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87124-1799
Country	:	US
Telephone Number	:	505-750-1069
Fax Number	:	844-714-2499

Authorized Official
Title or Position	:	OWNER
Name	:	NICOLE GREEN
Credential	:	LPCC, NCC
Telephone Number	:	505-750-1069

Provider Enumeration Date	:	03/24/2014
Last Update Date	:	07/08/2025

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Directions to “NICOLE GREEN LLC ” Practice Location

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