Provider Demographics
NPI:1518041771
Name:GREEN, DAVID L (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2685 LESLIE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-9607
Mailing Address - Country:US
Mailing Address - Phone:707-575-5355
Mailing Address - Fax:707-575-1491
Practice Address - Street 1:1101 B GALE WILSON BLVD STE 307
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3702
Practice Address - Country:US
Practice Address - Phone:707-428-3435
Practice Address - Fax:707-428-3770
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 9264103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical