Provider Demographics
NPI:1760810691
Name:GREEN, CHARLENE KIM (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:KIM
Last Name:GREEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9008 ELK GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9008 ELK GROVE BLVD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-1945
Practice Address - Country:US
Practice Address - Phone:916-544-0502
Practice Address - Fax:916-688-8603
Is Sole Proprietor?:No
Enumeration Date:2013-11-01
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73224106H00000X
CA86299106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA73224OtherBOARD OF BEHAVIOR SCIENCES
CA86299OtherBOARD OF BEHAVIORAL SCIENCES