Provider Demographics
NPI:1932800851
Name:GREEN, JOHN S
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 S HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-4935
Mailing Address - Country:US
Mailing Address - Phone:805-904-5083
Mailing Address - Fax:
Practice Address - Street 1:4456 MANZANITA AVE STE 2
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-7200
Practice Address - Country:US
Practice Address - Phone:802-487-9421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-16
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst