MEDICARE: DR. RANDY W. GREEN PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	005967	NY

General Provider Information

NPI Number	:	1881836120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDY W. GREEN PH.D.

Provider Business Mailing Address
First Line	:	7 VALDEMAR DR
Second Line	:
City	:	HOPEWELL JUNCTION
State	:	NY
Zip	:	12533-1253
Country	:	US
Telephone Number	:	845-226-2356
Fax Number	:	845-227-9540

Provider Business Practice Location Address
First Line	:	7 VALDEMAR RD
Second Line	:
City	:	HOPEWELL JUNCTION
State	:	NY
Zip	:	12533-6127
Country	:	US
Telephone Number	:	845-226-2356
Fax Number	:	845-227-9540

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2009
Last Update Date	:	04/01/2009

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