Provider Demographics
NPI:1225793094
Name:GREEN, LACEY DIANA (RBT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:DIANA
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 1:1500 S DOUGLAS RD STE 230
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4108
Mailing Address - Country:US
Mailing Address - Phone:844-244-1818
Mailing Address - Fax:
Practice Address - Street 1:8530 CINDER BED RD STE 1300
Practice Address - Street 2:
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1478
Practice Address - Country:US
Practice Address - Phone:703-782-5047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-05
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-191410106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician