=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285798009
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIE ANN GREEN M.S., M.F.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2460 W 3RD ST SUITE 220
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-6409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-795-0200
-----------------------------------------------------
Fax | 707-795-0200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2460 W 3RD ST SUITE 220
-----------------------------------------------------
City | SANTA ROSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95401-6409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-795-0200
-----------------------------------------------------
Fax | 707-795-0200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC33953
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------