Provider Demographics
NPI:1790871267
Name:GREEN, J. TIMOTHY (PHD)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:TIMOTHY
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:25255 CABOT ROAD SUITE 210
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653
Mailing Address - Country:US
Mailing Address - Phone:949-472-2353
Mailing Address - Fax:949-770-2440
Practice Address - Street 1:25255 CABOT ROAD SUITE 210
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-472-2353
Practice Address - Fax:949-770-2440
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPYS11187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical