MEDICARE: MR. FREDERICK GREEN II LMFT

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	106H00000X	Marriage & Family Therapist	138353	CA

General Provider Information

NPI Number	:	1700459500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREDERICK GREEN II LMFT

Provider Business Mailing Address
First Line	:	5270 APPLETON ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-1657
Country	:	US
Telephone Number	:	951-535-0979
Fax Number	:

Provider Business Practice Location Address
First Line	:	5270 APPLETON ST
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92504-1657
Country	:	US
Telephone Number	:	951-481-3815
Fax Number	:

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

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	03/28/2023

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