Provider Demographics
NPI:1053166983
Name:GREEN, MELODY (RBT)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18521 E QUEEN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5866
Mailing Address - Country:US
Mailing Address - Phone:480-361-1025
Mailing Address - Fax:
Practice Address - Street 1:18521 E QUEEN CREEK RD
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5866
Practice Address - Country:US
Practice Address - Phone:480-361-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRBT24341559106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician