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NPI Code Detail

MEDICARE: GREEN LEAF, A PSYCHOLOGICAL SERVICES CORPORATION

MEDICARE: GREEN LEAF, A PSYCHOLOGICAL SERVICES CORPORATION
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
1103T00000XPsychologist
2103TB0200XCognitive & Behavioral Psychologist
3103TC0700XClinical Psychologist
4103TC2200XClinical Child & Adolescent Psychologist
5103TF0000XFamily Psychologist
6103TS0200XSchool Psychologist
7104100000XSocial Worker
81041S0200XSchool Social Worker
9106H00000XMarriage & Family Therapist
10101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1639715907
Entity Type Code : Organization
Provider Name (Legal Business Name) : GREEN LEAF, A PSYCHOLOGICAL SERVICES CORPORATION
Provider Business Mailing Address
First Line : 302 VILLAGE SQ
Second Line :
City : ORINDA
State : CA
Zip : 94563-2506
Country : US
Telephone Number : 925-386-6037
Fax Number :
Provider Business Practice Location Address
First Line : 302 VILLAGE SQ
Second Line :
City : ORINDA
State : CA
Zip : 94563-2506
Country : US
Telephone Number : 925-386-6037
Fax Number :
Authorized Official
Title or Position : PRACTICE MANAGER
Name : DAVID JAMES MCCOLLUM
Credential :
Telephone Number : 925-386-6037
Provider Enumeration Date : 11/21/2019
Last Update Date : 11/21/2019

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