Provider Demographics
NPI:1194374215
Name:GREEN, DEREN ROBERT
Entity Type:Individual
Prefix:
First Name:DEREN
Middle Name:ROBERT
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 DEZARAE LOT #3
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253
Mailing Address - Country:US
Mailing Address - Phone:210-875-1437
Mailing Address - Fax:
Practice Address - Street 1:1401 DEZARAE LOT #3
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253
Practice Address - Country:US
Practice Address - Phone:210-875-1437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12145101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)