Healthcare Provider Details

I. General information

NPI: 1720114945
Provider Name (Legal Business Name): MS. DEI'ANDRA IESHA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N LOCUST AVE
COMPTON CA
90221-1323
US

IV. Provider business mailing address

2200 N LOCUST AVE
COMPTON CA
90221-1323
US

V. Phone/Fax

Practice location:
  • Phone: 310-279-0867
  • Fax:
Mailing address:
  • Phone: 310-279-0867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: