Provider Demographics
NPI:1346557246
Name:GREEN, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
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:P.O. BOX 2082
Mailing Address - Street 2:
Mailing Address - City:EL CERRITO
Mailing Address - State:CA
Mailing Address - Zip Code:94530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 MARIN AVENUE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:CA
Practice Address - Zip Code:94706-3289
Practice Address - Country:US
Practice Address - Phone:510-932-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA743631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical