Provider Demographics
NPI:1134280977
Name:GREEN, JUDITH O (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:O
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 1:15 SOUTH MAIN ST
Mailing Address - Street 2:SUITE 21
Mailing Address - City:SPRINGBURO
Mailing Address - State:OH
Mailing Address - Zip Code:45066
Mailing Address - Country:US
Mailing Address - Phone:937-748-0406
Mailing Address - Fax:937-748-2911
Practice Address - Street 1:15 SOUTH MAIN ST
Practice Address - Street 2:SUITE 21
Practice Address - City:SPRINGBURO
Practice Address - State:OH
Practice Address - Zip Code:45066
Practice Address - Country:US
Practice Address - Phone:937-748-0406
Practice Address - Fax:937-748-2911
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3861103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2225489Medicaid
OHCP21571Medicare ID - Type Unspecified