Healthcare Provider Details

I. General information

NPI: 1053644591
Provider Name (Legal Business Name): RYAN GREEN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2009
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 WOOD ST
EUREKA CA
95501-1117
US

IV. Provider business mailing address

720 WOOD ST
EUREKA CA
95501-1117
US

V. Phone/Fax

Practice location:
  • Phone: 707-382-7855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61473
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: