Healthcare Provider Details

I. General information

NPI: 1427436724
Provider Name (Legal Business Name): SUZANNE GREENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2015
Last Update Date: 01/31/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

638 CAMINO DE LOS MARES STE H130-518
SAN CLEMENTE CA
92673-2848
US

IV. Provider business mailing address

26137 LA PAZ RD STE 230
MISSION VIEJO CA
92691-5337
US

V. Phone/Fax

Practice location:
  • Phone: 949-203-5877
  • Fax:
Mailing address:
  • Phone: 949-595-8610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number132238
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: