Provider Demographics
NPI:1497648430
Name:GREEN, DESTINI (DCS)
Entity type:Individual
Prefix:
First Name:DESTINI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15957 TRAILHEAD RD
Mailing Address - Street 2:
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-5015
Mailing Address - Country:US
Mailing Address - Phone:405-808-6589
Mailing Address - Fax:
Practice Address - Street 1:15957 TRAILHEAD RD
Practice Address - Street 2:
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851-5015
Practice Address - Country:US
Practice Address - Phone:405-808-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-29
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent