MEDICARE: LISA GREEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1467645374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA GREEN

Provider Business Mailing Address
First Line	:	6711 ARLINGTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-1955
Country	:	US
Telephone Number	:	951-352-3943
Fax Number	:

Provider Business Practice Location Address
First Line	:	6711 ARLINGTON AVE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-1955
Country	:	US
Telephone Number	:	951-352-3943
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	08/23/2007

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Directions to “ LISA GREEN ” Practice Location

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