Provider Demographics
NPI:1467529776
Name:GREEN, MYRNA S (PHD, CA LICENSED P)
Entity Type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:S
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD, CA LICENSED P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 SHERMAN AVENUE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306
Mailing Address - Country:US
Mailing Address - Phone:650-328-1417
Mailing Address - Fax:650-424-8788
Practice Address - Street 1:440 SHERMAN AVENUE
Practice Address - Street 2:SUITE 103
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306
Practice Address - Country:US
Practice Address - Phone:650-328-1417
Practice Address - Fax:650-424-8788
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5092103TC0700X
CAPSY 5092103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist