Provider Demographics
NPI:1598833832
Name:GREEN, SUZANNE ELLEN (PHD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELLEN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 W ABIACA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328
Mailing Address - Country:US
Mailing Address - Phone:954-746-8415
Mailing Address - Fax:954-370-5967
Practice Address - Street 1:4399 N NOB HILL RD
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33351-5813
Practice Address - Country:US
Practice Address - Phone:954-746-8415
Practice Address - Fax:954-370-5967
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
59776Medicare ID - Type Unspecified