Healthcare Provider Details

I. General information

NPI: 1376002501
Provider Name (Legal Business Name): KATHRYN ROSE GREEN SUDCC #10771
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9462 VAN NUYS BLVD
VAN NUYS CA
91402-1310
US

IV. Provider business mailing address

9462 VAN NUYS BLVD
VAN NUYS CA
91402-1310
US

V. Phone/Fax

Practice location:
  • Phone: 818-692-4999
  • Fax:
Mailing address:
  • Phone: 818-891-8555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10771
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: