Healthcare Provider Details

I. General information

NPI: 1619538824
Provider Name (Legal Business Name): GREEN FAMILY TREE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 FOOTHILL BLVD STE 115
LA VERNE CA
91750-2949
US

IV. Provider business mailing address

2120 FOOTHILL BLVD STE 115
LA VERNE CA
91750-2949
US

V. Phone/Fax

Practice location:
  • Phone: 888-647-3622
  • Fax:
Mailing address:
  • Phone: 888-647-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDRIA L GREEN
Title or Position: EXECUTIVE DIRECTOR
Credential: SLP
Phone: 888-647-3622