Healthcare Provider Details

I. General information

NPI: 1679639215
Provider Name (Legal Business Name): PATRICIA ALEXANDRA GREEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 TAYLOR RD SUITE 1
LOOMIS CA
95650-9271
US

IV. Provider business mailing address

3805 TAYLOR RD SUITE 1
LOOMIS CA
95650-9271
US

V. Phone/Fax

Practice location:
  • Phone: 916-652-7470
  • Fax: 916-652-7065
Mailing address:
  • Phone: 916-652-7470
  • Fax: 916-652-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS16020
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: