Healthcare Provider Details

I. General information

NPI: 1154498269
Provider Name (Legal Business Name): RANDALL L GREEN PHD CLINICAL PSYCHOL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 D ST NE
SALEM OR
97301-2768
US

IV. Provider business mailing address

2250 D ST NE
SALEM OR
97301-2768
US

V. Phone/Fax

Practice location:
  • Phone: 503-364-6093
  • Fax: 503-364-5121
Mailing address:
  • Phone: 503-364-6093
  • Fax: 503-364-5121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number585
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: