Healthcare Provider Details

I. General information

NPI: 1356524367
Provider Name (Legal Business Name): LEE A GREEN PH D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 BAHIA VISTA ST SUITE 201
SARASOTA FL
34239-2635
US

IV. Provider business mailing address

2650 BAHIA VISTA ST SUITE 201
SARASOTA FL
34239-2635
US

V. Phone/Fax

Practice location:
  • Phone: 941-951-6504
  • Fax: 941-951-6433
Mailing address:
  • Phone: 941-951-6504
  • Fax: 941-951-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPY5323
License Number StateFL

VIII. Authorized Official

Name: DR. LEE A. GREEN
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 941-951-6504