Healthcare Provider Details

I. General information

NPI: 1841441938
Provider Name (Legal Business Name): DAVID GREEN, PH.D. & LOUISE GREEN, PH.D., APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5333 MISSION CENTER RD SUITE 354
SAN DIEGO CA
92108-1302
US

IV. Provider business mailing address

5333 MISSION CENTER RD SUITE 354
SAN DIEGO CA
92108-1302
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 Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY4422
License Number StateCA

VIII. Authorized Official

Name: LOUISE GREEN
Title or Position: VICE PRESIDENT
Credential: PH.D.
Phone: 619-281-0616