Provider Demographics
NPI:1104358233
Name:GREEN, CHARMAINE
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 MANOR PLAZA
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044
Mailing Address - Country:US
Mailing Address - Phone:650-355-8787
Mailing Address - Fax:650-355-8780
Practice Address - Street 1:480 MANOR PLAZA
Practice Address - Street 2:
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044
Practice Address - Country:US
Practice Address - Phone:650-355-8787
Practice Address - Fax:650-355-8780
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor