Healthcare Provider Details

I. General information

NPI: 1376362681
Provider Name (Legal Business Name): BRANDON GREEN PPSC, CWA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2024
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37720 FREMONT BLVD
FREMONT CA
94536-5025
US

IV. Provider business mailing address

38442 FREMONT BLVD
FREMONT CA
94536-6031
US

V. Phone/Fax

Practice location:
  • Phone: 510-505-7300
  • Fax:
Mailing address:
  • Phone: 510-505-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number230134369
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: