Healthcare Provider Details

I. General information

NPI: 1487379772
Provider Name (Legal Business Name): CREOLE GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2022
Last Update Date: 10/10/2022
Certification Date: 10/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W REDONDO BEACH BLVD STE 135
GARDENA CA
90247-4104
US

IV. Provider business mailing address

1045 W REDONDO BEACH BLVD STE 135
GARDENA CA
90247-4104
US

V. Phone/Fax

Practice location:
  • Phone: 310-553-2695
  • Fax:
Mailing address:
  • Phone: 310-553-2695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number7514
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: