=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184933947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN M GREEN PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2010
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38 STEWART AVE.
-----------------------------------------------------
City | STEWART MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-326-5530
-----------------------------------------------------
Fax | 516-326-0548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 STEWART AVE STEWART MANOR SCHOOL
-----------------------------------------------------
City | STEWART MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-326-5530
-----------------------------------------------------
Fax | 516-326-0548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC2200X
-----------------------------------------------------
Taxonomy Name | Clinical Child & Adolescent Psychologist
-----------------------------------------------------
License Number | 013227
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TS0200X
-----------------------------------------------------
Taxonomy Name | School Psychologist
-----------------------------------------------------
License Number | 013227
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------