Provider Demographics
NPI:1639495898
Name:GREEN, MARVA RENEE
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:RENEE
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 1:1315 N BULLIS RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-1650
Mailing Address - Country:US
Mailing Address - Phone:310-609-2303
Mailing Address - Fax:310-609-2403
Practice Address - Street 1:1315 N BULLIS RD
Practice Address - Street 2:SUITE 12
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90221-1650
Practice Address - Country:US
Practice Address - Phone:310-609-2303
Practice Address - Fax:310-609-2403
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACACOM21435042411A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)