Provider Demographics
NPI:1992914162
Name:GREEN, DANA MARIE (LPC, NCGC-II)
Entity type:Individual
Prefix:MRS
First Name:DANA
Middle Name:MARIE
Last Name:GREEN
Suffix:
Gender:F
Credentials:LPC, NCGC-II
Other - Prefix:MRS
Other - First Name:DANA
Other - Middle Name:BOLDT
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 1800
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-1800
Mailing Address - Country:US
Mailing Address - Phone:580-565-2252
Mailing Address - Fax:580-564-7187
Practice Address - Street 1:717B HIGHWAY 70 E
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-8253
Practice Address - Country:US
Practice Address - Phone:580-565-2252
Practice Address - Fax:580-564-7187
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2011101YM0800X
OKLPC2011103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst