Provider Demographics
NPI:1619604402
Name:GREEN, MARJORIE
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:91342-6506
Mailing Address - Country:US
Mailing Address - Phone:805-558-7209
Mailing Address - Fax:
Practice Address - Street 1:11600 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:LAKE VIEW TERRACE
Practice Address - State:CA
Practice Address - Zip Code:91342-6506
Practice Address - Country:US
Practice Address - Phone:818-868-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA15044101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program