=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598833832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUZANNE ELLEN GREEN PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2006
-----------------------------------------------------
Last Update Date | 09/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4399 N NOB HILL RD
-----------------------------------------------------
City | SUNRISE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33351-5813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-746-8415
-----------------------------------------------------
Fax | 954-370-5967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2921 W ABIACA CIRCLE
-----------------------------------------------------
City | DAVIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-746-8415
-----------------------------------------------------
Fax | 954-370-5967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | PY5213
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------