Healthcare Provider Details

I. General information

NPI: 1518041771
Provider Name (Legal Business Name): DAVID L. GREEN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 B GALE WILSON BLVD STE 307
FAIRFIELD CA
94533-3702
US

IV. Provider business mailing address

2685 LESLIE RD
SANTA ROSA CA
95404-9607
US

V. Phone/Fax

Practice location:
  • Phone: 707-428-3435
  • Fax: 707-428-3770
Mailing address:
  • Phone: 707-575-5355
  • Fax: 707-575-1491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 9264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: