Healthcare Provider Details

I. General information

NPI: 1588976385
Provider Name (Legal Business Name): SHULAMITE A GREEN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 VETERAN AVE
LOS ANGELES CA
90024-2704
US

IV. Provider business mailing address

660 CHARLES E YOUNG DR S
LOS ANGELES CA
90095-8347
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-6110
  • Fax:
Mailing address:
  • Phone: 323-361-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number27502
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: