Provider Demographics
NPI:1194435792
Name:GREEN, NICOLETTE
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2246 BOOTHILL CT STE 3
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-7213
Mailing Address - Country:US
Mailing Address - Phone:406-579-4984
Mailing Address - Fax:
Practice Address - Street 1:2246 BOOTHILL CT STE 3
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-7213
Practice Address - Country:US
Practice Address - Phone:406-579-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT59635101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health