Provider Demographics
NPI:1336367333
Name:GREEN, ERICA SUSAN
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:SUSAN
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:446 26TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-3026
Mailing Address - Country:US
Mailing Address - Phone:619-531-7095
Mailing Address - Fax:619-531-8745
Practice Address - Street 1:446 26TH ST FL 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-3026
Practice Address - Country:US
Practice Address - Phone:619-531-7095
Practice Address - Fax:619-531-8745
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CALCSW911141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)