Provider Demographics
NPI:1023162468
Name:GREEN, CORNELIA ELLIS (PHD)
Entity type:Individual
Prefix:DR
First Name:CORNELIA
Middle Name:ELLIS
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 PLEASANT ST
Mailing Address - Street 2:SUITE 313
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-6249
Mailing Address - Country:US
Mailing Address - Phone:608-365-7078
Mailing Address - Fax:608-365-7464
Practice Address - Street 1:419 PLEASANT ST
Practice Address - Street 2:SUITE 313
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6249
Practice Address - Country:US
Practice Address - Phone:608-365-7078
Practice Address - Fax:608-365-7464
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI951-057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39027300Medicaid