Provider Demographics
NPI:1073872214
Name:GREEN, GILLIAN (PHD)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 PARNASSUS AVE
Mailing Address - Street 2:BOX ADM-0984
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2211
Mailing Address - Country:US
Mailing Address - Phone:415-476-6931
Mailing Address - Fax:
Practice Address - Street 1:401 PARNASSUS AVE
Practice Address - Street 2:BOX ADM-0984
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2211
Practice Address - Country:US
Practice Address - Phone:415-476-6931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-09
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017202103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist