Provider Demographics
NPI:1164062261
Name:GREEN, DAWN RENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAWN
Middle Name:RENE
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 1:201 COUNTY ROAD 411
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-7629
Mailing Address - Country:US
Mailing Address - Phone:936-645-5120
Mailing Address - Fax:
Practice Address - Street 1:7272 WURZBACH RD STE 601
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4803
Practice Address - Country:US
Practice Address - Phone:210-615-3483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX38264OtherLICENSE