Provider Demographics
NPI:1255919262
Name:GREEN, CAMMY (LEP)
Entity type:Individual
Prefix:
First Name:CAMMY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 PORTAL AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1265
Mailing Address - Country:US
Mailing Address - Phone:415-730-8334
Mailing Address - Fax:
Practice Address - Street 1:1000 BROADWAY STE 460
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-4033
Practice Address - Country:US
Practice Address - Phone:415-730-8334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4029103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool