Healthcare Provider Details

I. General information

NPI: 1356456008
Provider Name (Legal Business Name): LOUISE B GREEN PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MISSION CENTER RD STE 354
SAN DIEGO CA
92108-1350
US

IV. Provider business mailing address

5333 MISSION CENTER RD 354
SAN DIEGO CA
92108
US

V. Phone/Fax

Practice location:
  • Phone: 619-281-0616
  • Fax: 619-528-1263
Mailing address:
  • Phone: 619-281-0616
  • Fax: 619-528-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPHY4422
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: