Provider Demographics
NPI:1033276431
Name:GREEN, WILLIAM M (PHD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:M
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83816-1209
Mailing Address - Country:US
Mailing Address - Phone:208-765-1894
Mailing Address - Fax:208-666-1598
Practice Address - Street 1:401 1 2 SHERMAN
Practice Address - Street 2:SUITE 206
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2777
Practice Address - Country:US
Practice Address - Phone:208-765-1894
Practice Address - Fax:208-666-1598
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY310103T00000X
CAPSY14247103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8050444Medicaid
ID8050444Medicaid