Provider Demographics
NPI:1750004248
Name:GREEN, SYDJEA M (PHD)
Entity type:Individual
Prefix:DR
First Name:SYDJEA
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 FLOYD ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-2646
Mailing Address - Country:US
Mailing Address - Phone:631-336-0695
Mailing Address - Fax:
Practice Address - Street 1:1230 N KIMBALL AVE STE 130
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4707
Practice Address - Country:US
Practice Address - Phone:833-667-7924
Practice Address - Fax:817-755-0945
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39576103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty