Provider Demographics
NPI:1295872455
Name:GREEN, VIRGINIA C (PHD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:C
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4727 W 164TH ST
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:CA
Mailing Address - Zip Code:90260-2824
Mailing Address - Country:US
Mailing Address - Phone:310-378-2520
Mailing Address - Fax:
Practice Address - Street 1:4727 W 164TH ST
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:CA
Practice Address - Zip Code:90260-2824
Practice Address - Country:US
Practice Address - Phone:310-378-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 35443101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health