Provider Demographics
NPI:1356456008
Name:GREEN, LOUISE B (PH D)
Entity Type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:B
Last Name:GREEN
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MISSION CENTER RD
Mailing Address - Street 2:354
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-281-0616
Mailing Address - Fax:619-528-1263
Practice Address - Street 1:5333 MISSION CENTER RD STE 354
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1350
Practice Address - Country:US
Practice Address - Phone:619-281-0616
Practice Address - Fax:619-528-1263
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY4422103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP4422Medicare ID - Type Unspecified