Provider Demographics
NPI:1407286008
Name:GREEN, STEVEN MICHAEL
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:MICHAEL
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 1:115 E BROADWAY
Mailing Address - Street 2:APT. L105
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1890
Mailing Address - Country:US
Mailing Address - Phone:202-509-3211
Mailing Address - Fax:
Practice Address - Street 1:100 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-3000
Practice Address - Country:US
Practice Address - Phone:202-509-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27523103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical