Provider Demographics
NPI:1336273374
Name:GREEN PH.D., ROBERTA DIANE (MSW, PHD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:DIANE
Last Name:GREEN PH.D.
Suffix:
Gender:F
Credentials:MSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1155 LIDA ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-2334
Mailing Address - Country:US
Mailing Address - Phone:626-585-8504
Mailing Address - Fax:626-584-6362
Practice Address - Street 1:1155 LIDA ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103-2334
Practice Address - Country:US
Practice Address - Phone:626-585-8504
Practice Address - Fax:626-584-6362
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 41571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical