Provider Demographics
NPI:1487328464
Name:GREEN, ROBERT ALLEN (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALLEN
Last Name:GREEN
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 HIGHLAND VIEW DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-6080
Mailing Address - Country:US
Mailing Address - Phone:318-834-6298
Mailing Address - Fax:
Practice Address - Street 1:113 FLAGG PL BLDG B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7025
Practice Address - Country:US
Practice Address - Phone:337-247-7282
Practice Address - Fax:337-279-0776
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA221575363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2584294Medicaid