Provider Demographics
NPI:1376362681
Name:GREEN, BRANDON (PPSC, CWA)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:PPSC, CWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38442 FREMONT BLVD
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-6031
Mailing Address - Country:US
Mailing Address - Phone:510-505-7300
Mailing Address - Fax:
Practice Address - Street 1:37720 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-5025
Practice Address - Country:US
Practice Address - Phone:510-505-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230134369101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool