Provider Demographics
NPI:1679025308
Name:GREEN, SYREETA (LMFT)
Entity Type:Individual
Prefix:
First Name:SYREETA
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16733 SUNHILL DR APT C108
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4556
Mailing Address - Country:US
Mailing Address - Phone:518-722-4919
Mailing Address - Fax:
Practice Address - Street 1:15437 ANACAPA RD STE 23
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2458
Practice Address - Country:US
Practice Address - Phone:518-722-4919
Practice Address - Fax:760-241-5974
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF79963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist