Healthcare Provider Details

I. General information

NPI: 1205346632
Provider Name (Legal Business Name): MARYANN R GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 10/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 CHESTNUT AVE
LONG BEACH CA
90813-1674
US

IV. Provider business mailing address

1775 CHESTNUT AVE
LONG BEACH CA
90813-1674
US

V. Phone/Fax

Practice location:
  • Phone: 562-599-8444
  • Fax: 562-599-8444
Mailing address:
  • Phone: 562-599-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number95061478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: