Provider Demographics
NPI:1326495268
Name:GREEN, LORI (MFT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 CAMINO DIABLO STE 210
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-3960
Mailing Address - Country:US
Mailing Address - Phone:925-786-1413
Mailing Address - Fax:
Practice Address - Street 1:2960 CAMINO DIABLO STE 210
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94597-3960
Practice Address - Country:US
Practice Address - Phone:925-786-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45255106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist