Provider Demographics
NPI:1629451588
Name:GREEN, FREDERICK WILLIAM III (PSYD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WILLIAM
Last Name:GREEN
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-2003
Mailing Address - Country:US
Mailing Address - Phone:207-317-0557
Mailing Address - Fax:
Practice Address - Street 1:51 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:REHOBOTH
Practice Address - State:MA
Practice Address - Zip Code:02769-2003
Practice Address - Country:US
Practice Address - Phone:207-317-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS01612103T00000X
WI3489103T00000X
MA11457103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist