Provider Demographics
NPI:1427704451
Name:GREEN, TARNELL JOSEPH
Entity type:Individual
Prefix:
First Name:TARNELL
Middle Name:JOSEPH
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MONTEBELLO RD APT 306C
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1347
Mailing Address - Country:US
Mailing Address - Phone:409-791-6442
Mailing Address - Fax:
Practice Address - Street 1:401 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2127
Practice Address - Country:US
Practice Address - Phone:719-387-7775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO205517106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician