Provider Demographics
NPI:1508850595
Name:GREEN, BERNARD L (PH D)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
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 1:1531 S MADISON ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-1800
Mailing Address - Country:US
Mailing Address - Phone:920-730-4411
Mailing Address - Fax:
Practice Address - Street 1:1531 S MADISON ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-1800
Practice Address - Country:US
Practice Address - Phone:920-730-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1272103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39042200Medicaid
WI028545300Medicare PIN
R81991Medicare UPIN