Provider Demographics
NPI:1588145098
Name:GREEN, RENETTA DENISE (LICENSED PROFESSIONA)
Entity type:Individual
Prefix:MS
First Name:RENETTA
Middle Name:DENISE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LICENSED PROFESSIONA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 HIGH GLEN CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7727
Mailing Address - Country:US
Mailing Address - Phone:803-237-6408
Mailing Address - Fax:
Practice Address - Street 1:FORT JACKSON/ACS 9810 LEE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207
Practice Address - Country:US
Practice Address - Phone:803-237-6408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6129101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional