Provider Demographics
NPI:1457417685
Name:GREEN, DAVID MICHAEL (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MICHAEL
Last Name:GREEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5333 MISSION CENTER RD
Mailing Address - Street 2:SUITE 354
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:619-281-0616
Mailing Address - Fax:619-528-1263
Practice Address - Street 1:3549 CAMINO DEL RIO S
Practice Address - Street 2:SUITE D
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4023
Practice Address - Country:US
Practice Address - Phone:619-281-0616
Practice Address - Fax:619-528-1263
Is Sole Proprietor?:No
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY4696103TC0700X, 103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49122YMedicaid
CAYYY49122YMedicaid