Healthcare Provider Details

I. General information

NPI: 1457417685
Provider Name (Legal Business Name): DAVID MICHAEL GREEN PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3549 CAMINO DEL RIO S SUITE D
SAN DIEGO CA
92108-4023
US

IV. Provider business mailing address

5333 MISSION CENTER RD SUITE 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 TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY4696
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPSY4696
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: