Healthcare Provider Details

I. General information

NPI: 1891379251
Provider Name (Legal Business Name): SARA GREEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2021
Last Update Date: 07/05/2021
Certification Date: 07/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 CABRILLO PARK DR STE 300
SANTA ANA CA
92701-5017
US

IV. Provider business mailing address

3424 GRANDE VISTA PKWY APT 255
RIVERSIDE CA
92503-0101
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-4455
  • Fax:
Mailing address:
  • Phone: 412-952-3765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: