Provider Demographics
NPI:1528935277
Name:GREEN, ERICK PATRICK JR
Entity type:Individual
Prefix:
First Name:ERICK
Middle Name:PATRICK
Last Name:GREEN
Suffix:JR
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 CROCKER WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8552
Mailing Address - Country:US
Mailing Address - Phone:925-813-2705
Mailing Address - Fax:
Practice Address - Street 1:605 STANDIFORD AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1000
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:866-500-2186
Is Sole Proprietor?:No
Enumeration Date:2025-10-18
Last Update Date:2025-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician