Provider Demographics
NPI:1083114342
Name:GREEN, BROOKE ALLISON (PHD)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ALLISON
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ALLISON
Other - Last Name:MCKAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:459 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96819-1522
Mailing Address - Country:US
Mailing Address - Phone:804-954-6389
Mailing Address - Fax:
Practice Address - Street 1:459 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1522
Practice Address - Country:US
Practice Address - Phone:804-954-6389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY1697103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical