Provider Demographics
NPI:1346393329
Name:GREEN, LEE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:A
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 1:2650 BAHIA VISTA ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2625
Mailing Address - Country:US
Mailing Address - Phone:941-951-6504
Mailing Address - Fax:941-951-6433
Practice Address - Street 1:2650 BAHIA VISTA ST STE 201
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2625
Practice Address - Country:US
Practice Address - Phone:941-951-6504
Practice Address - Fax:941-951-6433
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-21
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5323103TA0700X, 103TC0700X, 103TH0100X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59795Medicare ID - Type UnspecifiedPROVIDER NUMBER