Provider Demographics
NPI:1528138195
Name:GREEN, COLBY J (LPC)
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:J
Last Name:GREEN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 S EILER AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-9101
Mailing Address - Country:US
Mailing Address - Phone:417-781-7527
Mailing Address - Fax:
Practice Address - Street 1:530 E 34TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3924
Practice Address - Country:US
Practice Address - Phone:417-347-7530
Practice Address - Fax:417-347-7539
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006034060101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional