Provider Demographics
NPI:1730572579
Name:GREEN, AQUEELAH
Entity type:Individual
Prefix:MISS
First Name:AQUEELAH
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6484 W CHEYENNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-4927
Mailing Address - Country:US
Mailing Address - Phone:678-613-1501
Mailing Address - Fax:
Practice Address - Street 1:6484 W CHEYENNE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4927
Practice Address - Country:US
Practice Address - Phone:678-613-1501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst