Provider Demographics
NPI:1922203272
Name:GREEN, MARSHA ANN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARSHA
Middle Name:ANN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 494
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-0494
Mailing Address - Country:US
Mailing Address - Phone:503-728-8546
Mailing Address - Fax:
Practice Address - Street 1:710 E FOOTHILLS DR STE C
Practice Address - Street 2:SUITE 104
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6125
Practice Address - Country:US
Practice Address - Phone:503-728-8546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60146929103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470798717-26Medicaid
NE470798717-27Medicaid
NE470798717-29Medicaid