Provider Demographics
NPI:1619520491
Name:GREEN, CAMERON (LCSW)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 W 42ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W WASHINGTON BLVD # 104
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1247
Practice Address - Country:US
Practice Address - Phone:831-917-8910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-19
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 104100000X
CA930801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker