Provider Demographics
NPI:1346334711
Name:GREENE, SUSAN MARINEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MARINEL
Last Name:GREENE
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 1:11100 SAN PABLO AVE
Mailing Address - Street 2:SUITE 216
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530-2194
Mailing Address - Country:US
Mailing Address - Phone:510-233-8402
Mailing Address - Fax:510-233-8402
Practice Address - Street 1:11100 SAN PABLO AVE
Practice Address - Street 2:SUITE 216
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-2194
Practice Address - Country:US
Practice Address - Phone:510-233-8402
Practice Address - Fax:510-233-8402
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY6684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY066840Medicaid
CA00PL66840Medicare ID - Type Unspecified