Healthcare Provider Details

I. General information

NPI: 1457786485
Provider Name (Legal Business Name): CASSIE M GREEN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1577 CONGRESS ST
PORTLAND ME
04102-2169
US

IV. Provider business mailing address

27 HAWTHORNE LN
SOUTH PORTLAND ME
04106-6935
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5522
  • Fax:
Mailing address:
  • Phone: 207-590-4171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPSY.0004257
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: